Healthcare Provider Details

I. General information

NPI: 1871133934
Provider Name (Legal Business Name): AGAPE COMMUNITY HEALTH MOBILE UNIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 EDGEWOOD AVE W
JACKSONVILLE FL
32208-3021
US

IV. Provider business mailing address

5460 BLANDING BLVD
JACKSONVILLE FL
32244-1957
US

V. Phone/Fax

Practice location:
  • Phone: 904-760-4904
  • Fax:
Mailing address:
  • Phone: 904-800-6347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: SHENITA SMITH
Title or Position: BUSINESS COORDINATOR
Credential:
Phone: 904-800-6347