Provider Demographics
NPI:1326312315
Name:IM SULZBACHER CENTER FOR THE HOMELESS INC
Entity Type:Organization
Organization Name:IM SULZBACHER CENTER FOR THE HOMELESS INC
Other - Org Name:BEACHES COMMUNITY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH SERVICES ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-394-8056
Mailing Address - Street 1:611 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-2847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 6TH AVE S STE 500
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4200
Practice Address - Country:US
Practice Address - Phone:904-224-3550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IM SULZBACHER CENTER FOR THE HOMELESS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-08
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL686032002261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686032002Medicaid