Healthcare Provider Details

I. General information

NPI: 1093852741
Provider Name (Legal Business Name): CEREBRAL PALSY OF NORTHEAST FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 BEACH BLVD
JACKSONVILLE FL
32207-3704
US

IV. Provider business mailing address

3311 BEACH BLVD
JACKSONVILLE FL
32207-3704
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-1462
  • Fax: 904-396-1199
Mailing address:
  • Phone: 904-396-1462
  • Fax: 904-396-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. HOLLY PETERS
Title or Position: CEO PRESIDENT
Credential:
Phone: 904-396-1462