MEDICARE: SOLANTIC OF JACKSONVILLE, 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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1811662836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLANTIC OF JACKSONVILLE, LLC

Provider Business Mailing Address
First Line	:	115 EASTPARK DR STE 300
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-2311
Country	:	US
Telephone Number	:	615-600-4100
Fax Number	:

Provider Business Practice Location Address
First Line	:	2032 DUNN AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-4716
Country	:	US
Telephone Number	:	904-757-2008
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	SIERRA MANNING
Credential	:
Telephone Number	:	904-900-5436

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	08/11/2021

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