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General NPI Number Information
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NPI Number | 1841548898
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Entity Type | Organization
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Legal Business Name | PEACHESNABASKET ADULT HEALTH SERVICES
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Dates
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Enumeration Date | 08/23/2012
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Last Update Date | 08/23/2012
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Provider Practice Location Address
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Address Line | 2040 SOUTEL DR
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City | JACKSONVILLE
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State | FL
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Zip | 32208-2280
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Country | US
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Telephone | 904-766-4993
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Fax | 904-713-9966
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Provider Business Mailing Address
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Address Line | 2040 SOUTEL DR
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City | JACKSONVILLE
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State | FL
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Zip | 32208-2280
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Country | US
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Telephone | 904-766-4993
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Fax | 904-713-9966
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Authorized Official
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Title or Position | CEO
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Name | MS. B.DOLORES FLEMMING
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Credential | MS
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Telephone | 904-766-4993
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 231670
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License Number State | FL
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