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General NPI Number Information
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NPI Number | 1922883925
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Entity Type | Organization
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Legal Business Name | FREEDOM LLC
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Dates
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Enumeration Date | 08/28/2023
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Last Update Date | 08/28/2023
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Provider Practice Location Address
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Address Line | 4131 UNIVERSITY BLVD S STE 10
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City | JACKSONVILLE
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State | FL
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Zip | 32216-4346
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Country | US
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Telephone | 508-769-2707
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Fax |
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Provider Business Mailing Address
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Address Line | 244 SILVER GLEN AVE
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32092-2470
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Country | US
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Telephone | 508-769-2707
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | BORIS BERGUS
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Credential | MD
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Telephone | 508-769-2707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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