Provider Demographics
NPI:1811208804
Name:PEACHES-NA-BASKET ADULT DAY CARE CENTER, INC.
Entity Type:Organization
Organization Name:PEACHES-NA-BASKET ADULT DAY CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:DOLORES
Authorized Official - Last Name:FLEMMING
Authorized Official - Suffix:
Authorized Official - Credentials:MS, NHA
Authorized Official - Phone:904-766-4993
Mailing Address - Street 1:2040 SOUTEL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-2280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2040 SOUTEL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-2280
Practice Address - Country:US
Practice Address - Phone:904-766-4993
Practice Address - Fax:904-713-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL672949500Medicaid