=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669987293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OBI'S ADULT FAMILY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2017
-----------------------------------------------------
Last Update Date | 04/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3130 KINGSTON ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32254-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-728-7474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3130 KINGSTON ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32254-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-728-7474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAKAELA OBI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-728-7474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906906
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------