Provider Demographics
NPI:1396369187
Name:IM SULZBACHER CENTER FOR THE HOMELESS, INC
Entity Type:Organization
Organization Name:IM SULZBACHER CENTER FOR THE HOMELESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNKHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-394-4958
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:904-394-5481
Mailing Address - Fax:
Practice Address - Street 1:5455 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5166
Practice Address - Country:US
Practice Address - Phone:904-394-4958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty