Healthcare Provider Details

I. General information

NPI: 1487218939
Provider Name (Legal Business Name): FLAGLER PROFESSIONAL HEALTH CARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PALENCIA VILLAGE DR STE 108
ST AUGUSTINE FL
32095-8553
US

IV. Provider business mailing address

PO BOX 3266
ST AUGUSTINE FL
32085-3266
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-3200
  • Fax: 904-819-3201
Mailing address:
  • Phone: 904-819-4602
  • Fax: 904-819-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN FRANKS
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 904-819-4065