Healthcare Provider Details

I. General information

NPI: 1821435603
Provider Name (Legal Business Name): OWL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 COLES CT
SAINT JOHNS FL
32259-8898
US

IV. Provider business mailing address

87 COLES CT
SAINT JOHNS FL
32259-8898
US

V. Phone/Fax

Practice location:
  • Phone: 904-755-4720
  • Fax:
Mailing address:
  • Phone: 904-755-4720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: DR. LASTER BERNARD WALKER
Title or Position: PRESIDENT/CEO
Credential: PHD
Phone: 904-755-4720