Provider Demographics
NPI:1083752885
Name:THE FANNIE E. TAYLOR HOME FOR THE AGED, INC.
Entity Type:Organization
Organization Name:THE FANNIE E. TAYLOR HOME FOR THE AGED, INC.
Other - Org Name:TAYLOR HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. FINANCE & ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERBURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-636-0313
Mailing Address - Street 1:6601 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2252
Mailing Address - Country:US
Mailing Address - Phone:904-636-0313
Mailing Address - Fax:904-367-0021
Practice Address - Street 1:3937 SPRING PARK RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5739
Practice Address - Country:US
Practice Address - Phone:904-636-0313
Practice Address - Fax:904-367-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1149095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105820Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID