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General NPI Number Information
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NPI Number | 1578892485
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Entity Type | Organization
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Legal Business Name | GRANDMARY'S HOUSE
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Dates
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Enumeration Date | 12/24/2009
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Last Update Date | 12/24/2009
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Provider Practice Location Address
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Address Line | 4828 EVANSTON RD
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City | JACKSONVILLE
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State | FL
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Zip | 32208
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Country | US
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Telephone | 904-768-8350
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Fax |
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Provider Business Mailing Address
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Address Line | 4828 EVANSTON RD JACKSONVILLE
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City | JACKSONVILLE
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State | FL
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Zip | 32208-1840
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | PROF. MARY A ROBINSON
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Credential |
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Telephone | 904-768-8350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number | 59062583
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License Number State | MI
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