=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114403185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY FIRST SOLUTION COMMUNITY DEVELOPMENT CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2018
-----------------------------------------------------
Last Update Date | 07/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12280 SUMTER SQUARE DR W
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-622-8684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12280 SUMTER SQUARE DR W
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-6125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-622-8684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. ASZLOYN NIKITA WAKEFIELD
-----------------------------------------------------
Credential | ED.S.
-----------------------------------------------------
Telephone | 904-622-8684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------