Healthcare Provider Details

I. General information

NPI: 1386066728
Provider Name (Legal Business Name): RIVER WATCH ACUTE TRAUMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2014
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

13737 NOEL RD STE 1600
DALLAS TX
75240-1374
US

V. Phone/Fax

Practice location:
  • Phone: 904-276-8500
  • Fax:
Mailing address:
  • Phone: 954-838-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: OFFICER
Credential:
Phone: 973-251-1132