Healthcare Provider Details

I. General information

NPI: 1104259019
Provider Name (Legal Business Name): FLORIDA DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 TIMUQUANA RD SUITE 9
JACKSONVILLE FL
32210-8959
US

IV. Provider business mailing address

900 UNIVERSITY BLVD N MC-75
JACKSONVILLE FL
32211-9230
US

V. Phone/Fax

Practice location:
  • Phone: 904-253-1120
  • Fax: 904-253-2514
Mailing address:
  • Phone: 904-253-2062
  • Fax: 904-253-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLI T WELLS
Title or Position: DIRECTOR
Credential: M.D.
Phone: 904-253-2062