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General NPI Number Information
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NPI Number | 1265199434
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Entity Type | Organization
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Legal Business Name | DURRANCE MEDICAID PROVIDERS LLC
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Dates
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Enumeration Date | 11/23/2021
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Last Update Date | 11/23/2021
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Provider Practice Location Address
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Address Line | 9257 SW 137TH ST
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City | STARKE
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State | FL
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Zip | 32091-5974
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Country | US
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Telephone | 904-226-5719
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Fax |
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Provider Business Mailing Address
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Address Line | 9257 SW 137TH ST
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City | STARKE
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State | FL
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Zip | 32091-5974
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Country | US
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Telephone | 904-226-5719
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JEFFREY DURRANCE
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Credential |
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Telephone | 904-226-5719
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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