Provider Demographics
NPI:1205669546
Name:WILEY'S COVE
Entity type:Organization
Organization Name:WILEY'S COVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:904-598-4229
Mailing Address - Street 1:25 N MARKET ST # 258
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-2802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 N MARKET ST # 258
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-2802
Practice Address - Country:US
Practice Address - Phone:904-598-4229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-22
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care