Provider Demographics
NPI:1033412184
Name:CITRUS HEALTH NETWORK INC
Entity Type:Organization
Organization Name:CITRUS HEALTH NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:E
Authorized Official - Last Name:JARDON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:305-424-3100
Mailing Address - Street 1:4175 W 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5874
Mailing Address - Country:US
Mailing Address - Phone:305-424-3100
Mailing Address - Fax:305-825-1645
Practice Address - Street 1:4125 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5874
Practice Address - Country:US
Practice Address - Phone:305-424-3100
Practice Address - Fax:305-825-1645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL744441261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL688571300Medicaid