Provider Demographics
NPI:1407026016
Name:NORTHEAST FLORIDA HEALTH SERVICES INC
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA HEALTH SERVICES INC
Other - Org Name:FAMILY HEALTH SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-624-1054
Mailing Address - Street 1:1205 S WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7466
Mailing Address - Country:US
Mailing Address - Phone:386-740-2056
Mailing Address - Fax:386-749-2280
Practice Address - Street 1:844 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3284
Practice Address - Country:US
Practice Address - Phone:386-738-2422
Practice Address - Fax:386-738-2423
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-11
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687955102Medicaid