Healthcare Provider Details

I. General information

NPI: 1245142835
Provider Name (Legal Business Name): JOSE RAUL VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 LONE CYPRESS WAY
ST AUGUSTINE FL
32092-0157
US

IV. Provider business mailing address

399 LONE CYPRESS WAY
ST AUGUSTINE FL
32092-0157
US

V. Phone/Fax

Practice location:
  • Phone: 305-215-0240
  • Fax:
Mailing address:
  • Phone: 305-215-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: