MEDICARE: SRC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1841686433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRC

Provider Business Mailing Address
First Line	:	11993 ALEXANDRA DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-8880
Country	:	US
Telephone Number	:	678-886-3984
Fax Number	:

Provider Business Practice Location Address
First Line	:	580 ELLIS RD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-3582
Country	:	US
Telephone Number	:	678-886-3984
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH COUNSELOR
Name	:	TANYA LAKE-SMITH
Credential	:
Telephone Number	:	678-886-3984

Provider Enumeration Date	:	04/09/2015
Last Update Date	:	04/09/2015

Similar Medicare Providers

1326415662 — MS. JACQUELINE BAKER MH21380
Practice Location Address:

580 ELLIS RD S
JACKSONVILLE, FL
32254-3582

Practice Phone: 904-423-0017
Practice Fax:

1467843052 — MRS. MUNTRELLA REGINA WOODARD MASTERS OF ART
Practice Location Address:

580 ELLIS RD S
JACKSONVILLE, FL
32254-3582

Practice Phone: 904-423-0017
Practice Fax: 904-683-8169

1285027029 — MELISSA MORROW LAMB
Practice Location Address:

580 ELLIS RD S , STE 118
JACKSONVILLE, FL
32254-3582

Practice Phone: 904-423-0017
Practice Fax:

1679948699 — ROSE MARIE PENA
Practice Location Address:

580 ELLIS RD S , SUITE 118
JACKSONVILLE, FL
32254-3582

Practice Phone: 904-423-0017
Practice Fax: 904-683-8169

1003273244 — SOUTH REHABILITATION CENTER, INC.
Practice Location Address:

580 ELLIS RD S , SUITE 118
JACKSONVILLE, FL
32254-3582

Practice Phone: 904-423-0017
Practice Fax: 904-683-8169

1003275678 — STEPHANIE CHERYL BOSH MS, MCAP
Practice Location Address:

580 ELLIS RD S
JACKSONVILLE, FL
32254-3582

Practice Phone: 904-423-0017
Practice Fax:

Directions to “SRC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.