Healthcare Provider Details

I. General information

NPI: 1174761613
Provider Name (Legal Business Name): BAKER COUNTY HOSPITAL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N 3RD ST
MACCLENNY FL
32063-2103
US

IV. Provider business mailing address

159 N 3RD ST
MACCLENNY FL
32063-2103
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-3151
  • Fax: 904-259-3279
Mailing address:
  • Phone: 904-259-3151
  • Fax: 904-259-3279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1581096
License Number StateFL

VIII. Authorized Official

Name: MR. GLENN MCKENDREE
Title or Position: CHAIRMAN OF BOARD
Credential:
Phone: 904-259-3151