=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053065540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITH WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2022
-----------------------------------------------------
Last Update Date | 02/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5298 SUNBEAM RD STE 8
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-6292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-621-0748
-----------------------------------------------------
Fax | 904-212-5810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13836 GABRIEL CT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-7213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-333-5980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. CHANTINA DAVIS
-----------------------------------------------------
Credential | PHYSICIAN ASSISTANT
-----------------------------------------------------
Telephone | 904-621-0748
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------