Healthcare Provider Details

I. General information

NPI: 1275891178
Provider Name (Legal Business Name): HAMPTON'S LUXURY VILLAS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10695 HAMPTON RD
JACKSONVILLE FL
32257-6905
US

IV. Provider business mailing address

10695 HAMPTON RD
JACKSONVILLE FL
32257-6905
US

V. Phone/Fax

Practice location:
  • Phone: 904-232-8575
  • Fax: 904-328-3850
Mailing address:
  • Phone: 904-232-8575
  • Fax: 904-328-3850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberAL#12086
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberAL#12086
License Number StateFL

VIII. Authorized Official

Name: MR. HENNIE CARIAS WITHERUP
Title or Position: PRESIDENT/CEO
Credential:
Phone: 904-536-3091