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General NPI Number Information
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NPI Number | 1538595657
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Entity Type | Organization
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Legal Business Name | ORANGE PARK ASSISTED LIVING FACILITY, INC.
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Dates
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Enumeration Date | 09/20/2013
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Last Update Date | 09/20/2013
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Provider Practice Location Address
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Address Line | 2485 RIDGECREST AVE
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City | ORANGE PARK
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State | FL
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Zip | 32065-6236
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Country | US
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Telephone | 904-276-6644
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Fax | 904-276-6644
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Provider Business Mailing Address
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Address Line | 2485 RIDGECREST AVE
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City | ORANGE PARK
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State | FL
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Zip | 32065-6236
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Country | US
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Telephone | 904-276-6644
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Fax | 904-276-6644
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | MARIE JENKINS
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Credential |
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Telephone | 904-673-1419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL12390
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License Number State | FL
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