Healthcare Provider Details

I. General information

NPI: 1710648316
Provider Name (Legal Business Name): FIRST COAST COMMUNITY DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N NEWNAN ST
JACKSONVILLE FL
32202-3121
US

IV. Provider business mailing address

525 N NEWNAN ST
JACKSONVILLE FL
32202-3121
US

V. Phone/Fax

Practice location:
  • Phone: 904-379-8383
  • Fax: 904-358-5618
Mailing address:
  • Phone: 904-379-8383
  • Fax: 904-358-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLIE GRIFFIN
Title or Position: CEO/PRESIDENT
Credential:
Phone: 904-866-7483