Healthcare Provider Details

I. General information

NPI: 1205805421
Provider Name (Legal Business Name): ORANGE PARK EXTENDED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 FLEMING PLANTATION BLVD
ORANGE PARK FL
32003-3389
US

IV. Provider business mailing address

1125 FLEMING PLANTATION BLVD
FLEMING ISLAND FL
32003-3389
US

V. Phone/Fax

Practice location:
  • Phone: 904-245-7620
  • Fax: 904-213-8338
Mailing address:
  • Phone: 904-541-3500
  • Fax: 904-213-8338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number130471035
License Number StateFL

VIII. Authorized Official

Name: MS. DONNA J. MARSH
Title or Position: BOOKKEEPER
Credential:
Phone: 386-255-1054