Provider Demographics
NPI:1275113565
Name:PRESTIGE SENIOR CARE
Entity Type:Organization
Organization Name:PRESTIGE SENIOR CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-545-5481
Mailing Address - Street 1:8450 GATE PKWY W UNIT 1330
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1072
Mailing Address - Country:US
Mailing Address - Phone:904-545-5481
Mailing Address - Fax:
Practice Address - Street 1:10151 DEERWOOD PARK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0566
Practice Address - Country:US
Practice Address - Phone:800-438-6702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-11
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1154907897OtherHOME HEALTH AIDE