Healthcare Provider Details

I. General information

NPI: 1861548562
Provider Name (Legal Business Name): ST JOHNS COUNTY WELFARE FEDERATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 MARINE ST
ST AUGUSTINE FL
32084-5154
US

IV. Provider business mailing address

161 MARINE ST
ST AUGUSTINE FL
32084-5154
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-3475
  • Fax: 904-808-9908
Mailing address:
  • Phone: 904-829-3475
  • Fax: 904-808-9908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1489096
License Number StateFL

VIII. Authorized Official

Name: LARRY LAKE
Title or Position: ADMINISTRATOR
Credential: PHD, NHA
Phone: 904-824-2501