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General NPI Number Information
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NPI Number | 1154133296
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Entity Type | Organization
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Legal Business Name | THE PALISADES AT EWU
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Dates
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Enumeration Date | 01/24/2025
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Last Update Date | 01/24/2025
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Provider Practice Location Address
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Address Line | 1156 W 4TH ST
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City | JACKSONVILLE
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State | FL
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Zip | 32209-7704
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Country | US
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Telephone | 904-610-5628
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Fax |
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Provider Business Mailing Address
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Address Line | 77007 MERRILL RD UNIT 8309
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City | JACKSONVILLE
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State | FL
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Zip | 32277
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Country | US
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Telephone | 904-610-5628
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KENKENYANA ROBERTS
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Credential |
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Telephone | 904-610-5628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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