Healthcare Provider Details

I. General information

NPI: 1346733185
Provider Name (Legal Business Name): DUESEASON1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 SAINT AUGUSTINE RD
JACKSONVILLE FL
32207
US

IV. Provider business mailing address

731 DUVAL STATION RD STE 107
JACKSONVILLE FL
32218-0801
US

V. Phone/Fax

Practice location:
  • Phone: 904-504-8855
  • Fax:
Mailing address:
  • Phone: 904-504-8855
  • Fax: 904-683-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TONYA HALL
Title or Position: MEMBER
Credential:
Phone: 904-504-8855