MEDICARE: RUBY BEACH BEHAVIORAL PEDIATRICS 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	103K00000X	Behavior Analyst

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	:	1407527385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUBY BEACH BEHAVIORAL PEDIATRICS LLC

Provider Business Mailing Address
First Line	:	12086 FORT CAROLINE RD STE 102
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-2688
Country	:	US
Telephone Number	:	904-415-1609
Fax Number	:

Provider Business Practice Location Address
First Line	:	12086 FORT CAROLINE RD STE 102
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-2688
Country	:	US
Telephone Number	:	904-415-1609
Fax Number	:	904-485-8298

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MS. MEGAN T ALEXANDER
Credential	:
Telephone Number	:	904-415-1609

Provider Enumeration Date	:	09/21/2021
Last Update Date	:	09/21/2021

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