Healthcare Provider Details

I. General information

NPI: 1902574635
Provider Name (Legal Business Name): SOLANTIC OF JACKSONVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463941 SR 200
YULEE FL
32097
US

IV. Provider business mailing address

115 EASTPARK DR
BRENTWOOD TN
37027-7548
US

V. Phone/Fax

Practice location:
  • Phone: 904-572-1959
  • Fax:
Mailing address:
  • Phone: 615-600-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SIERRA MANNING
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 904-900-5436