Provider Demographics
NPI:1154644912
Name:LP JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:LP JACKSONVILLE, LLC
Other - Org Name:SIGNATURE HEALTHCARE OF JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-568-7800
Mailing Address - Street 1:2061 HYDE PARK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3815
Mailing Address - Country:US
Mailing Address - Phone:904-786-7331
Mailing Address - Fax:904-786-4034
Practice Address - Street 1:2061 HYDE PARK RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3815
Practice Address - Country:US
Practice Address - Phone:904-786-7331
Practice Address - Fax:904-786-4034
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LP O HOLDINGS II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-09
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF10800961313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
10-5287Medicare UPIN