Healthcare Provider Details

I. General information

NPI: 1417791500
Provider Name (Legal Business Name): PEACOCK COMPANION & CAREGIVING SERIVCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 07/20/2024
Certification Date: 07/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 WILLOW ST
JACKSONVILLE FL
32207-4458
US

IV. Provider business mailing address

2918 WILLOW ST
JACKSONVILLE FL
32207-4458
US

V. Phone/Fax

Practice location:
  • Phone: 904-882-5777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LA'RONIQUIA BRE'NAE FLEMING
Title or Position: OWNER
Credential:
Phone: 904-254-0469