MEDICARE: M-K OF FERNANDINA BEACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	SNF1457096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063411668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M-K OF FERNANDINA BEACH

Provider Business Mailing Address
First Line	:	1625 LIME ST
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-3017
Country	:	US
Telephone Number	:	904-261-0771
Fax Number	:	904-261-3909

Provider Business Practice Location Address
First Line	:	1625 LIME ST
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-3017
Country	:	US
Telephone Number	:	904-261-0771
Fax Number	:	904-261-3909

Authorized Official
Title or Position	:	NURSING HOME ADMINISTRATOR
Name	:	MRS. LYNDA MILLER
Credential	:
Telephone Number	:	904-261-0771

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	10/16/2008

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