Provider Demographics
NPI:1316381890
Name:STEPHENS MEMORIAL HOME
Entity Type:Organization
Organization Name:STEPHENS MEMORIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-797-0294
Mailing Address - Street 1:5805 DATIL PEPPER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5699
Mailing Address - Country:US
Mailing Address - Phone:904-797-0294
Mailing Address - Fax:904-797-6372
Practice Address - Street 1:5805 DATIL PEPPER RD
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5699
Practice Address - Country:US
Practice Address - Phone:904-797-0294
Practice Address - Fax:904-797-6372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10189310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685603900Medicaid