Provider Demographics
NPI:1033194279
Name:IHS OF FLORIDA AT JACKSONVILLE INC
Entity Type:Organization
Organization Name:IHS OF FLORIDA AT JACKSONVILLE INC
Other - Org Name:WEST JACKSONVILLE HEALTH AND REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-513-8738
Mailing Address - Street 1:1650 FOURAKER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221
Mailing Address - Country:US
Mailing Address - Phone:904-786-8668
Mailing Address - Fax:904-695-0166
Practice Address - Street 1:1650 FOURAKER RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221
Practice Address - Country:US
Practice Address - Phone:904-786-8668
Practice Address - Fax:904-695-0166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1087096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL218171Medicaid
FL218171Medicaid