Provider Demographics
NPI:1548580012
Name:DE URGENT CARE JAX PA
Entity Type:Organization
Organization Name:DE URGENT CARE JAX PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-881-7754
Mailing Address - Street 1:13457 ATLANTIC BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3293
Mailing Address - Country:US
Mailing Address - Phone:904-221-9110
Mailing Address - Fax:904-220-9110
Practice Address - Street 1:13457 ATLANTIC BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3293
Practice Address - Country:US
Practice Address - Phone:904-221-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC9323OtherAHCA