Healthcare Provider Details

I. General information

NPI: 1609359249
Provider Name (Legal Business Name): CAREMAX CLINIC 711 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2732 TROLLIE LN
JACKSONVILLE FL
32211-3833
US

IV. Provider business mailing address

PO BOX 600365
JACKSONVILLE FL
32260-0365
US

V. Phone/Fax

Practice location:
  • Phone: 904-289-1254
  • Fax: 904-212-0036
Mailing address:
  • Phone: 904-289-1254
  • Fax: 904-202-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VIPUL B MAMTORA
Title or Position: DIRECTOR
Credential:
Phone: 904-289-1254