Provider Demographics
NPI:1467907626
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:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-202-6025
Mailing Address - Street 1:1205 S WOODLAND BLVD STE 7
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:386-202-6025
Mailing Address - Fax:386-269-4149
Practice Address - Street 1:1205 S WOODLAND BLVD STE 3
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7464
Practice Address - Country:US
Practice Address - Phone:386-202-6025
Practice Address - Fax:386-202-1755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-17
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687955117Medicaid
FL687955117Medicaid
FL687955118Medicaid