Provider Demographics
NPI:1497497234
Name:RIVER REGION HUMAN SERVICES RESIDENTIAL
Entity Type:Organization
Organization Name:RIVER REGION HUMAN SERVICES RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-317-3214
Mailing Address - Street 1:3901 CARMICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2325
Mailing Address - Country:US
Mailing Address - Phone:904-899-6300
Mailing Address - Fax:
Practice Address - Street 1:2981 PARENTAL HOME RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5797
Practice Address - Country:US
Practice Address - Phone:904-899-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER REGION HUMAN SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1046918OtherDCF