Provider Demographics
NPI:1417192022
Name:IPS OF JACKSONVILLE LLC
Entity Type:Organization
Organization Name:IPS OF JACKSONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NOBACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-360-1566
Mailing Address - Street 1:PO BOX 864483
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-4483
Mailing Address - Country:US
Mailing Address - Phone:888-337-3509
Mailing Address - Fax:
Practice Address - Street 1:4754 E STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9058
Practice Address - Country:US
Practice Address - Phone:888-337-3509
Practice Address - Fax:941-328-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1176261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical