Healthcare Provider Details

I. General information

NPI: 1184305435
Provider Name (Legal Business Name): 904 HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4427 EMERSON ST STE A
JACKSONVILLE FL
32207-4969
US

IV. Provider business mailing address

221 N HOGAN ST STE 118
JACKSONVILLE FL
32202-4201
US

V. Phone/Fax

Practice location:
  • Phone: 904-659-2475
  • Fax:
Mailing address:
  • Phone: 904-900-1513
  • Fax: 904-575-4944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES TARVER
Title or Position: DIRECTOR
Credential:
Phone: 904-403-2079