MEDICARE: JACKSONVILLE OPCO 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1609652478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE OPCO LLC

Provider Business Mailing Address
First Line	:	144 SHADY LANE DR
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-2351
Country	:	US
Telephone Number	:	732-364-2444
Fax Number	:

Provider Business Practice Location Address
First Line	:	5888 BLANDING BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-1927
Country	:	US
Telephone Number	:	718-916-1443
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED MEMBER
Name	:	JOE NEUMAN
Credential	:
Telephone Number	:	718-916-1443

Provider Enumeration Date	:	09/06/2023
Last Update Date	:	09/06/2023

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