Provider Demographics
NPI:1851711279
Name:SHIPP ADULT FAMILY CARE HOME
Entity Type:Organization
Organization Name:SHIPP ADULT FAMILY CARE HOME
Other - Org Name:DELOIS SHIPP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DELOIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-766-1850
Mailing Address - Street 1:8942 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-2126
Mailing Address - Country:US
Mailing Address - Phone:904-766-1850
Mailing Address - Fax:
Practice Address - Street 1:8942 6TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-2126
Practice Address - Country:US
Practice Address - Phone:904-766-1850
Practice Address - Fax:904-766-1850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAF33320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141412700Medicaid