Healthcare Provider Details

I. General information

NPI: 1366770133
Provider Name (Legal Business Name): MT. MORIAH UNITED METHODIST CHURCH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2009
Last Update Date: 12/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3919 SAINT AUGUSTINE RD
JACKSONVILLE FL
32207-6638
US

IV. Provider business mailing address

3919 SAINT AUGUSTINE RD
JACKSONVILLE FL
32207-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-6918
  • Fax: 904-396-1444
Mailing address:
  • Phone: 904-396-6918
  • Fax: 904-396-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number9038
License Number StateFL

VIII. Authorized Official

Name: DELORIS DEMPS
Title or Position: ADMINISTRATOR
Credential:
Phone: 904-396-6918