=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083121412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST COAST CAREGIVERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2018
-----------------------------------------------------
Last Update Date | 01/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3733 UNIVERSITY BLVD W STE 212
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32217-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-394-3203
-----------------------------------------------------
Fax | 904-485-8882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3733 UNIVERSITY BLVD W STE 212
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32217-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-394-3203
-----------------------------------------------------
Fax | 904-485-8882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GARY S JURENOVICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-394-3203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 299994392
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------