MEDICARE: FINCA DE SAN JUAN, LLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1215718002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FINCA DE SAN JUAN, LLC

Provider Business Mailing Address
First Line	:	1370 13TH AVE S STE 218
Second Line	:
City	:	JAX BCH
State	:	FL
Zip	:	32250-3206
Country	:	US
Telephone Number	:	904-853-6154
Fax Number	:	877-543-5924

Provider Business Practice Location Address
First Line	:	1370 13TH AVE S STE 218
Second Line	:
City	:	JAX BCH
State	:	FL
Zip	:	32250-3206
Country	:	US
Telephone Number	:	904-853-6154
Fax Number	:	877-543-5924

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	RONDA CREWS
Credential	:	APRN
Telephone Number	:	904-853-6154

Provider Enumeration Date	:	10/09/2023
Last Update Date	:	10/09/2023

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Directions to “FINCA DE SAN JUAN, LLC ” Practice Location

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