Healthcare Provider Details

I. General information

NPI: 1699487678
Provider Name (Legal Business Name): 904 HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96040 LOFTON SQUARE CT
YULEE FL
32097-6347
US

IV. Provider business mailing address

221 N HOGAN ST STE 118
JACKSONVILLE FL
32202-4201
US

V. Phone/Fax

Practice location:
  • Phone: 904-659-2475
  • Fax: 904-453-8600
Mailing address:
  • Phone: 904-659-2475
  • Fax: 904-453-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WENDY KELLY
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 563-650-2158