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General NPI Number Information
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NPI Number | 1063411668
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Entity Type | Organization
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Legal Business Name | M-K OF FERNANDINA BEACH
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Dates
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Enumeration Date | 07/18/2005
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Last Update Date | 10/16/2008
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Provider Practice Location Address
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Address Line | 1625 LIME ST
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City | FERNANDINA BEACH
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State | FL
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Zip | 32034-3017
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Country | US
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Telephone | 904-261-0771
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Fax | 904-261-3909
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Provider Business Mailing Address
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Address Line | 1625 LIME ST
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City | FERNANDINA BEACH
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State | FL
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Zip | 32034-3017
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Country | US
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Telephone | 904-261-0771
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Fax | 904-261-3909
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Authorized Official
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Title or Position | NURSING HOME ADMINISTRATOR
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Name | MRS. LYNDA MILLER
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Credential |
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Telephone | 904-261-0771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | SNF1457096
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License Number State | FL
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