Provider Demographics
NPI:1497758312
Name:TEN BROECK JACKSONVILLE LLC
Entity Type:Organization
Organization Name:TEN BROECK JACKSONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-876-2200
Mailing Address - Street 1:6300 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2708
Mailing Address - Country:US
Mailing Address - Phone:904-724-9202
Mailing Address - Fax:904-724-3797
Practice Address - Street 1:6300 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2708
Practice Address - Country:US
Practice Address - Phone:904-724-9202
Practice Address - Fax:904-724-3797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4011283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075144816Medicaid
FL104016Medicare Oscar/Certification