Healthcare Provider Details

I. General information

NPI: 1750398541
Provider Name (Legal Business Name): LOVING CARE LIVING FACILITY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BRUEN ST
ST AUGUSTINE FL
32084-3406
US

IV. Provider business mailing address

PO BOX 588
ST AUGUSTINE FL
32085-0588
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-6616
  • Fax: 904-797-7440
Mailing address:
  • Phone: 904-824-6616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL8149
License Number StateFL

VIII. Authorized Official

Name: MR. THOMAS J JACKSON II
Title or Position: BUSINESS MGR/OWNER
Credential: M.P.A.
Phone: 904-824-6616