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General NPI Number Information
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NPI Number | 1265680805
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Entity Type | Organization
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Legal Business Name | NEW HEAVEN DOMINION, INC
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Dates
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Enumeration Date | 09/08/2008
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Last Update Date | 09/12/2008
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Provider Practice Location Address
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Address Line | 9146 RIDGE BRIER LN
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City | JACKSONVILLE
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State | FL
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Zip | 32225-9325
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Country | US
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Telephone | 904-647-6651
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Fax | 904-647-6653
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Provider Business Mailing Address
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Address Line | 12355 FINNS COVE TRL
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City | JACKSONVILLE
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State | FL
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Zip | 32246-4198
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Country | US
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Telephone | 904-790-0721
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Fax | 904-619-6025
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. BRIAN ARTHUR GEORGE
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Credential |
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Telephone | 904-790-0721
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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 | 02084206
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License Number State | FL
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