Healthcare Provider Details

I. General information

NPI: 1962867762
Provider Name (Legal Business Name): AGAPE COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 KING ST
JACKSONVILLE FL
32204-2410
US

IV. Provider business mailing address

120 KING ST
JACKSONVILLE FL
32204-2410
US

V. Phone/Fax

Practice location:
  • Phone: 904-760-4904
  • Fax: 904-930-4607
Mailing address:
  • Phone: 904-760-4904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberN04000004094
License Number StateFL

VIII. Authorized Official

Name: MS. MIA L JONES
Title or Position: CEO
Credential:
Phone: 904-253-1069