Provider Demographics
NPI:1679350722
Name:SKILLED NURSING INFECTIOUS DISEASE LLC
Entity Type:Organization
Organization Name:SKILLED NURSING INFECTIOUS DISEASE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-673-5553
Mailing Address - Street 1:PO BOX 23338
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241
Mailing Address - Country:US
Mailing Address - Phone:904-673-5553
Mailing Address - Fax:904-641-1017
Practice Address - Street 1:6817 SOUTHPOINT PARKWAY #801
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-537-3765
Practice Address - Fax:904-641-1017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty