Healthcare Provider Details

I. General information

NPI: 1467881292
Provider Name (Legal Business Name): ST JOHNS WELFARE FEDERATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 11/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161B MARINE ST
ST AUGUSTINE FL
32084-5104
US

IV. Provider business mailing address

161A MARINE ST
ST AUGUSTINE FL
32084-5154
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-3780
  • Fax: 904-829-2740
Mailing address:
  • Phone: 904-829-3475
  • Fax: 904-808-9918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9470
License Number StateFL

VIII. Authorized Official

Name: SUZANNE EDWARDS
Title or Position: RESIDENT ACCOUNTS SUPERVISOR
Credential:
Phone: 904-584-1563