Provider Demographics
NPI:1023788569
Name:NAUTILUS HEALTH CARE GROUP, LLC
Entity type:Organization
Organization Name:NAUTILUS HEALTH CARE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIENCKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-446-3519
Mailing Address - Street 1:5220 BELFORT RD STE 130
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6018
Mailing Address - Country:US
Mailing Address - Phone:904-446-3686
Mailing Address - Fax:904-446-3032
Practice Address - Street 1:11371 CORTEZ BLVD STE 134
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5408
Practice Address - Country:US
Practice Address - Phone:352-606-7182
Practice Address - Fax:352-606-7482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-16
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty