Healthcare Provider Details

I. General information

NPI: 1205664349
Provider Name (Legal Business Name): 3455 SAN PABLO RD S TENANT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 SAN PABLO RD S
JACKSONVILLE FL
32224-3803
US

IV. Provider business mailing address

8415 E 21ST ST N STE 100
WICHITA KS
67206-2959
US

V. Phone/Fax

Practice location:
  • Phone: 904-821-8030
  • Fax:
Mailing address:
  • Phone: 316-616-6288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: SHARON MAKOWSKY
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 419-247-2800