Provider Demographics
NPI:1003899550
Name:INTERIM HHA OF ST. AUGUSTINE
Entity Type:Organization
Organization Name:INTERIM HHA OF ST. AUGUSTINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-704-2407
Mailing Address - Street 1:6950 PHILIPS HIGHWAY, SUITE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-448-1133
Mailing Address - Fax:904-448-9130
Practice Address - Street 1:3440 US 1 S
Practice Address - Street 2:BUILDING 400, SUITE 404
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6363
Practice Address - Country:US
Practice Address - Phone:904-824-6123
Practice Address - Fax:904-829-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHHA20589096251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
10-7264Medicare ID - Type Unspecified