Healthcare Provider Details

I. General information

NPI: 1114331501
Provider Name (Legal Business Name): ALICIA MITCHELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5583 OAK CROSSING CT
JACKSONVILLE FL
32244-8202
US

IV. Provider business mailing address

5583 OAK CROSSING COURT
JACKSONVILLE FL
32244
US

V. Phone/Fax

Practice location:
  • Phone: 904-219-8551
  • Fax:
Mailing address:
  • Phone: 904-219-8551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ALICIA MITCHELL
Title or Position: PROVIDER
Credential:
Phone: 904-219-8551