Healthcare Provider Details

I. General information

NPI: 1609543503
Provider Name (Legal Business Name): NORTHEAST FLORIDA HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/27/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 FREDERICK ST
PIERSON FL
32180-3024
US

IV. Provider business mailing address

1205 S WOODLAND BLVD STE 3
DELAND FL
32720-7464
US

V. Phone/Fax

Practice location:
  • Phone: 386-749-9449
  • Fax: 386-749-9447
Mailing address:
  • Phone: 386-202-6025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: REBECCA COLLIER
Title or Position: CREDENTIALING/CONTRACTS ADMIN
Credential:
Phone: 386-202-6025