Provider Demographics
NPI:1134669823
Name:JACKSONVILLE GROUP SUPPLY INC
Entity Type:Organization
Organization Name:JACKSONVILLE GROUP SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:Z
Authorized Official - Last Name:RAVELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-763-8467
Mailing Address - Street 1:8130 BAYMEADOWS CIR W STE 308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1812
Mailing Address - Country:US
Mailing Address - Phone:904-763-8467
Mailing Address - Fax:
Practice Address - Street 1:8130 BAYMEADOWS CIR W STE 308
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1812
Practice Address - Country:US
Practice Address - Phone:904-763-8467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies