MEDICARE: NE FLORIDA ENTERPRISES, 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	253Z00000X	In Home Supportive Care Agency	234803	FL
2	253Z00000X	In Home Supportive Care Agency	299994713	FL

General Provider Information

NPI Number	:	1285127688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NE FLORIDA ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	101 MARKETSIDE AVE # 404-168
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-1541
Country	:	US
Telephone Number	:	904-201-3566
Fax Number	:

Provider Business Practice Location Address
First Line	:	10175 FORTUNE PKWY UNIT 202
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6748
Country	:	US
Telephone Number	:	904-201-3566
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND OPERATING PRINCIPAL
Name	:	KIMBERLEY SCHAFER
Credential	:
Telephone Number	:	904-201-3566

Provider Enumeration Date	:	06/11/2018
Last Update Date	:	06/11/2018

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