=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295114221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANAM PARC, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2015
-----------------------------------------------------
Last Update Date | 05/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4867 SUSANNA WOODS CT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-5266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-732-9509
-----------------------------------------------------
Fax | 904-732-9510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3604 CARDINAL POINT DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-5581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-610-6602
-----------------------------------------------------
Fax | 904-731-0002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MS. JAMIE LOUISE GLAVICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-610-6602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12320
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------