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General NPI Number Information
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NPI Number | 1275113565
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Entity Type | Organization
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Legal Business Name | PRESTIGE SENIOR CARE
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Dates
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Enumeration Date | 04/11/2021
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Last Update Date | 04/11/2021
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Provider Practice Location Address
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Address Line | 10151 DEERWOOD PARK BLVD STE 250
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City | JACKSONVILLE
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State | FL
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Zip | 32256-0566
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Country | US
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Telephone | 800-438-6702
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Fax |
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Provider Business Mailing Address
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Address Line | 8450 GATE PKWY W UNIT 1330
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City | JACKSONVILLE
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State | FL
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Zip | 32216-1072
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Country | US
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Telephone | 904-545-5481
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIMBERLY MIX
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Credential | MD
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Telephone | 904-545-5481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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