Healthcare Provider Details

I. General information

NPI: 1841065794
Provider Name (Legal Business Name): ROOTED NORTHEAST FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9521 SHELLIE RD STE 11
JACKSONVILLE FL
32257-6174
US

IV. Provider business mailing address

9521 SHELLIE RD STE 11
JACKSONVILLE FL
32257-6174
US

V. Phone/Fax

Practice location:
  • Phone: 904-428-0990
  • Fax:
Mailing address:
  • Phone: 904-428-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARA STERLING
Title or Position: MANAGER
Credential:
Phone: 904-464-1074