Provider Demographics
NPI:1407630148
Name:SOH OF FLORIDA PA
Entity Type:Organization
Organization Name:SOH OF FLORIDA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-362-4986
Mailing Address - Street 1:1584 KINGSLEY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1584 KINGSLEY AVE STE A
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4515
Practice Address - Country:US
Practice Address - Phone:904-990-0926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOH OF FLORIDA PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty