=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265529887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL HOSPITAL-WEST VOLUSIA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 06/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 W GRANADA BLVD STE 203
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-5179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-943-4522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 W. PLYMOUTH AVENUE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-943-4522
-----------------------------------------------------
Fax | 386-943-3674
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JONATHAN ARMSTRONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-497-8195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | 4436
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------