Provider Demographics
NPI:1689019556
Name:CHRISTIAN FAMILY CARE HOME
Entity Type:Organization
Organization Name:CHRISTIAN FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAGOBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-724-2052
Mailing Address - Street 1:1350 EDDY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-6223
Mailing Address - Country:US
Mailing Address - Phone:904-724-2052
Mailing Address - Fax:904-721-6641
Practice Address - Street 1:1350 EDDY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-6223
Practice Address - Country:US
Practice Address - Phone:904-724-2052
Practice Address - Fax:904-721-6641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7884310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility