Provider Demographics
NPI:1073280988
Name:FSL JAX BEACH TENANT LLC.
Entity Type:Organization
Organization Name:FSL JAX BEACH TENANT LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CRAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-877-1717
Mailing Address - Street 1:1240 E INDEPENDENCE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4201
Mailing Address - Country:US
Mailing Address - Phone:417-877-1717
Mailing Address - Fax:
Practice Address - Street 1:1315 2ND AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3694
Practice Address - Country:US
Practice Address - Phone:904-829-6479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility