MEDICARE: WILEY'S COVE

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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1205669546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILEY'S COVE

Provider Business Mailing Address
First Line	:	25 N MARKET ST # 258
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32202-2802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 N MARKET ST # 258
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32202-2802
Country	:	US
Telephone Number	:	904-598-4229
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATASHA WILEY
Credential	:	NP
Telephone Number	:	904-598-4229

Provider Enumeration Date	:	08/22/2024
Last Update Date	:	01/14/2025

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