Healthcare Provider Details

I. General information

NPI: 1225544208
Provider Name (Legal Business Name): TIKI STAFFORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 N MYRTLE AVE
JACKSONVILLE FL
32209-4231
US

IV. Provider business mailing address

3225 N MYRTLE AVE
JACKSONVILLE FL
32209-4231
US

V. Phone/Fax

Practice location:
  • Phone: 904-233-1090
  • Fax:
Mailing address:
  • Phone: 904-233-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL11951
License Number StateFL

VIII. Authorized Official

Name: TIKI STAFFORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 904-233-1090