Provider Demographics
NPI:1053656199
Name:SAN JUAN RETIREMENT HOME
Entity Type:Organization
Organization Name:SAN JUAN RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ALF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELVIRA
Authorized Official - Middle Name:CHUA
Authorized Official - Last Name:DEMDAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-695-9605
Mailing Address - Street 1:6561 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2857
Mailing Address - Country:US
Mailing Address - Phone:904-695-9605
Mailing Address - Fax:904-693-1973
Practice Address - Street 1:6561 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2857
Practice Address - Country:US
Practice Address - Phone:904-695-9605
Practice Address - Fax:904-693-1973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9587311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)