MEDICARE: NEW HEAVEN DOMINION, INC

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	251S00000X	Community/Behavioral Health Agency	02084206	FL

General Provider Information

NPI Number	:	1265680805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW HEAVEN DOMINION, INC

Provider Business Mailing Address
First Line	:	12355 FINNS COVE TRL
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-4198
Country	:	US
Telephone Number	:	904-790-0721
Fax Number	:	904-619-6025

Provider Business Practice Location Address
First Line	:	9146 RIDGE BRIER LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-9325
Country	:	US
Telephone Number	:	904-647-6651
Fax Number	:	904-647-6653

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. BRIAN ARTHUR GEORGE
Credential	:
Telephone Number	:	904-790-0721

Provider Enumeration Date	:	09/08/2008
Last Update Date	:	09/12/2008

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