Provider Demographics
NPI:1275970204
Name:AGNES STREET HOME FOR THE ELDERLY
Entity Type:Organization
Organization Name:AGNES STREET HOME FOR THE ELDERLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ATAKELTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADMASU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-766-7651
Mailing Address - Street 1:1346 AGNES ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-3302
Mailing Address - Country:US
Mailing Address - Phone:904-766-7651
Mailing Address - Fax:904-766-7668
Practice Address - Street 1:1346 AGNES ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3302
Practice Address - Country:US
Practice Address - Phone:904-766-7651
Practice Address - Fax:904-766-7668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5745310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142605200Medicaid