MEDICARE: SALUD PRIMARY CARE 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	363LP2300X	Primary Care Nurse Practitioner

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	:	1730774142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALUD PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	379 TINTAMARRE DR
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32092-1102
Country	:	US
Telephone Number	:	904-625-2644
Fax Number	:

Provider Business Practice Location Address
First Line	:	1126 UNIVERSITY BLVD N STE 3105
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-8850
Country	:	US
Telephone Number	:	904-625-2644
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOHANNA RUSSELL
Credential	:	NP
Telephone Number	:	904-625-2644

Provider Enumeration Date	:	03/08/2021
Last Update Date	:	03/08/2021

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Directions to “SALUD PRIMARY CARE LLC ” Practice Location

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