MEDICARE: WEST JAX SKILLED NURSING

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	207Q00000X	Family Medicine Physician	1285048280	FL
2	207Q00000X	Family Medicine Physician	1750382669	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	:	1063898864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST JAX SKILLED NURSING

Provider Business Mailing Address
First Line	:	100 CYPRESS LAGOON CT
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-2106
Country	:	US
Telephone Number	:	904-783-2405
Fax Number	:	904-786-4981

Provider Business Practice Location Address
First Line	:	100 CYPRESS LAGOON CT
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-2106
Country	:	US
Telephone Number	:	904-783-2405
Fax Number	:	904-786-4981

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	DR. MICHAEL VICTOR SHARPE
Credential	:	M.D.
Telephone Number	:	904-783-2405

Provider Enumeration Date	:	08/04/2015
Last Update Date	:	08/04/2015

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