Provider Demographics
NPI:1184296832
Name:FIRST COAST COMMUNITY SUPPORT SERVICES
Entity type:Organization
Organization Name:FIRST COAST COMMUNITY SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:904-738-8579
Mailing Address - Street 1:5300 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3142
Mailing Address - Country:US
Mailing Address - Phone:904-738-8579
Mailing Address - Fax:904-619-7835
Practice Address - Street 1:5300 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3142
Practice Address - Country:US
Practice Address - Phone:904-738-8579
Practice Address - Fax:904-619-7835
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIRST COAST COMMUNITY SUPPORT SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103272401Medicaid