Provider Demographics
NPI:1679730824
Name:CLAY COUNTY COUNCIL ON AGING, INC.
Entity Type:Organization
Organization Name:CLAY COUNTY COUNCIL ON AGING, INC.
Other - Org Name:(DBA) COUNCIL ON AGING OF CLAY COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DECANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-531-5020
Mailing Address - Street 1:604 WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3322
Mailing Address - Country:US
Mailing Address - Phone:904-284-3134
Mailing Address - Fax:904-284-0296
Practice Address - Street 1:604 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-3322
Practice Address - Country:US
Practice Address - Phone:904-284-5977
Practice Address - Fax:904-284-0296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5666302R00000X
FL302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070035500Medicaid