Healthcare Provider Details

I. General information

NPI: 1639229834
Provider Name (Legal Business Name): BOYS HOME ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2354 UNIVERSITY BLVD N
JACKSONVILLE FL
32211-3228
US

IV. Provider business mailing address

2354 UNIVERSITY BLVD N
JACKSONVILLE FL
32211-3228
US

V. Phone/Fax

Practice location:
  • Phone: 904-421-6040
  • Fax: 904-744-8131
Mailing address:
  • Phone: 904-421-6040
  • Fax: 904-744-8131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. COLLEEN SURMAN
Title or Position: DIRECTOR OF MEDICAID SERVICES
Credential:
Phone: 904-421-6040