Provider Demographics
NPI:1083381974
Name:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND CONTRACTS ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-202-6025
Mailing Address - Street 1:1205 S WOODLAND BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7464
Mailing Address - Country:US
Mailing Address - Phone:386-202-6025
Mailing Address - Fax:
Practice Address - Street 1:801 BEVILLE RD STE 101&102
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1860
Practice Address - Country:US
Practice Address - Phone:386-267-6214
Practice Address - Fax:386-999-0414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687955112Medicaid