Healthcare Provider Details

I. General information

NPI: 1912193673
Provider Name (Legal Business Name): MANDIC GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-7855
US

IV. Provider business mailing address

5155 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-7855
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-5027
  • Fax: 904-797-5577
Mailing address:
  • Phone: 904-797-5027
  • Fax: 904-797-5577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number4075096
License Number StateFL

VIII. Authorized Official

Name: MR. MARK MANDIC
Title or Position: OWNER/PRES.
Credential:
Phone: 904-797-5027