Provider Demographics
NPI:1053305748
Name:SOUTHERN THERAPIES OF NORTH FLORIDA INC
Entity Type:Organization
Organization Name:SOUTHERN THERAPIES OF NORTH FLORIDA INC
Other - Org Name:SOUTHERN THERAPY AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-312-0022
Mailing Address - Street 1:6050 SAINT JOHNS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3895
Mailing Address - Country:US
Mailing Address - Phone:386-312-0022
Mailing Address - Fax:386-312-0535
Practice Address - Street 1:6050 SAINT JOHNS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3895
Practice Address - Country:US
Practice Address - Phone:386-312-0022
Practice Address - Fax:386-312-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)Group - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6762204-00Medicaid
FL884914500Medicaid
FL884914500Medicaid