=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780667220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERIM HEALTHCARE OF JACKSONVILLE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2005
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2233 PARK AVE SUITE 304
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-527-2030
-----------------------------------------------------
Fax | 904-621-0968
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7999 PHILIPS HWY SUITE 304
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-4443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-448-1133
-----------------------------------------------------
Fax | 904-448-9130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. GLENN ROBIN REEVES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-448-1133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HHA205710961
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------