Healthcare Provider Details

I. General information

NPI: 1649885054
Provider Name (Legal Business Name): TAMBOLINA ADULT DAY CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 ROGERO RD # 1627
JACKSONVILLE FL
32211-4866
US

IV. Provider business mailing address

1627 ROGERO RD # 1627
JACKSONVILLE FL
32211-4866
US

V. Phone/Fax

Practice location:
  • Phone: 904-651-1544
  • Fax: 904-240-0309
Mailing address:
  • Phone: 904-651-1544
  • Fax: 904-240-0309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMBA MEDZA MOMORIE
Title or Position: PRESIDEN
Credential: EDD
Phone: 904-629-9922