Healthcare Provider Details

I. General information

NPI: 1326383852
Provider Name (Legal Business Name): OPERATION COMMUNITY RESTORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N WASHINGTON ST
JACKSONVILLE FL
32202-2809
US

IV. Provider business mailing address

204 N WASHINGTON ST
JACKSONVILLE FL
32202-2809
US

V. Phone/Fax

Practice location:
  • Phone: 904-352-1417
  • Fax: 904-352-1416
Mailing address:
  • Phone: 904-352-1417
  • Fax: 904-352-1416

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 Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. LADI ANITA MARCH
Title or Position: OWNER
Credential:
Phone: 904-352-1417