Healthcare Provider Details

I. General information

NPI: 1720075351
Provider Name (Legal Business Name): SOVEREIGN HEALTHCARE OF MACCLENNY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S 5TH ST
MACCLENNY FL
32063-2685
US

IV. Provider business mailing address

5887 GLENRIDGE DR SUITE 150
ATLANTA GA
30328-5574
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-4873
  • Fax: 904-259-5381
Mailing address:
  • Phone: 404-574-2100
  • Fax: 404-574-2105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1222096
License Number StateFL

VIII. Authorized Official

Name: MR. R. MARK CRONQUIST
Title or Position: MANAGER
Credential:
Phone: 404-574-2100