MEDICARE: NORTHEAST FLORIDA HEALTH SERVICES, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)
2	207Q00000X	Family Medicine Physician

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	:	1790452688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST FLORIDA HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	1205 S WOODLAND BLVD STE 3
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-7464
Country	:	US
Telephone Number	:	386-202-6025
Fax Number	:

Provider Business Practice Location Address
First Line	:	2160 HOWLAND BLVD STE 110
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32738-3468
Country	:	US
Telephone Number	:	386-532-0515
Fax Number	:	386-532-0516

Authorized Official
Title or Position	:	CEO
Name	:	LAURIE ASBURY
Credential	:
Telephone Number	:	386-749-9449

Provider Enumeration Date	:	08/27/2021
Last Update Date	:	08/27/2021

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