Provider Demographics
NPI:1083037329
Name:DEBRA'S ADULT FAMILY CARE HOME
Entity Type:Organization
Organization Name:DEBRA'S ADULT FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ALTHEA
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-379-0354
Mailing Address - Street 1:3957 VICTORIA LAKES DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-0710
Mailing Address - Country:US
Mailing Address - Phone:904-379-0354
Mailing Address - Fax:
Practice Address - Street 1:3957 VICTORIA LAKES DR S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-0710
Practice Address - Country:US
Practice Address - Phone:904-379-0354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906605311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home