Provider Demographics
NPI:1700855939
Name:JACKSONVILLE EXTENDED CARE, LLC
Entity Type:Organization
Organization Name:JACKSONVILLE EXTENDED CARE, LLC
Other - Org Name:SOUTHPOINT TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:380-255-1054
Mailing Address - Street 1:4325 SOUTHPOINT BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6166
Mailing Address - Country:US
Mailing Address - Phone:904-245-7620
Mailing Address - Fax:904-281-9956
Practice Address - Street 1:4325 SOUTHPOINT BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6166
Practice Address - Country:US
Practice Address - Phone:904-245-7620
Practice Address - Fax:904-281-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL130471028314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026628100Medicaid
FL026628100Medicaid