=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194261248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JBS ADULT FAMILY CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2017
-----------------------------------------------------
Last Update Date | 03/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2718 SHENANDOAH DR S
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-6628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-602-5389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2718 SHENANDOAH DR S
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-6628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | BRENETH GUTING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-602-5389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906875
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------