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General NPI Number Information
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NPI Number | 1063898864
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Entity Type | Organization
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Legal Business Name | WEST JAX SKILLED NURSING
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Dates
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Enumeration Date | 08/04/2015
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Last Update Date | 08/04/2015
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Provider Practice Location Address
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Address Line | 100 CYPRESS LAGOON CT
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-2106
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Country | US
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Telephone | 904-783-2405
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Fax | 904-786-4981
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Provider Business Mailing Address
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Address Line | 100 CYPRESS LAGOON CT
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-2106
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Country | US
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Telephone | 904-783-2405
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Fax | 904-786-4981
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Authorized Official
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Title or Position | SUPERVISOR
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Name | DR. MICHAEL VICTOR SHARPE
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Credential | M.D.
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Telephone | 904-783-2405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 1285048280
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 1750382669
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License Number State | FL
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