Provider Demographics
NPI:1710051354
Name:IM SULZBACHER CENTER FOR THE HOMELESS, INC
Entity Type:Organization
Organization Name:IM SULZBACHER CENTER FOR THE HOMELESS, INC
Other - Org Name:SULZBACHER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:904-394-8056
Mailing Address - Street 1:611 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-2847
Mailing Address - Country:US
Mailing Address - Phone:904-394-8070
Mailing Address - Fax:
Practice Address - Street 1:611 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-2847
Practice Address - Country:US
Practice Address - Phone:904-394-8070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6860320 00261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6860320 00Medicaid