MEDICARE: PEMBERLEY ADMINISTRATIVE SERVICES, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1790202711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEMBERLEY ADMINISTRATIVE SERVICES, LLC

Provider Business Mailing Address
First Line	:	1175 WESTWOOD DR
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-9293
Country	:	US
Telephone Number	:	904-466-1106
Fax Number	:

Provider Business Practice Location Address
First Line	:	157 HAMPTON POINT DR STE 1
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-3054
Country	:	US
Telephone Number	:	904-466-1106
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LISA BRITT
Credential	:
Telephone Number	:	904-466-1106

Provider Enumeration Date	:	08/30/2017
Last Update Date	:	08/30/2017

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