Provider Demographics
NPI:1942612502
Name:SAN JOSE FAMILY DENISTRY
Entity Type:Organization
Organization Name:SAN JOSE FAMILY DENISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEMAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-737-8081
Mailing Address - Street 1:9310 OLD KINGS RD S STE 601
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-6178
Mailing Address - Country:US
Mailing Address - Phone:904-737-8081
Mailing Address - Fax:904-737-3343
Practice Address - Street 1:9310 OLD KINGS RD S STE 601
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6178
Practice Address - Country:US
Practice Address - Phone:904-737-8081
Practice Address - Fax:904-737-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1407867237OtherNPI
FLDN0010974OtherSTATE LICENSE