Provider Demographics
NPI:1912193673
Name:MANDIC GROUP INC
Entity Type:Organization
Organization Name:MANDIC GROUP INC
Other - Org Name:D/B/A ST. AUGUSTINE CENTER FOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-797-5027
Mailing Address - Street 1:5155 US HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7855
Mailing Address - Country:US
Mailing Address - Phone:904-797-5027
Mailing Address - Fax:904-797-5577
Practice Address - Street 1:5155 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7855
Practice Address - Country:US
Practice Address - Phone:904-797-5027
Practice Address - Fax:904-797-5577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4075096320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities