=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285077248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRING GARDENS OF ORANGE PARK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2013
-----------------------------------------------------
Last Update Date | 04/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 SANDLEWOOD CIR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-8928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-276-1778
-----------------------------------------------------
Fax | 888-736-5589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2550 SANDLEWOOD CIR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-8928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-276-1778
-----------------------------------------------------
Fax | 888-736-5589
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. DORINDA JENIPHER WILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-891-8793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12321
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------