Provider Demographics
NPI:1396904439
Name:PORTER'S AULT CARE
Entity type:Organization
Organization Name:PORTER'S AULT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LASHANA
Authorized Official - Middle Name:MEDINA
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-381-8962
Mailing Address - Street 1:700 DAY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-5504
Mailing Address - Country:US
Mailing Address - Phone:904-381-8962
Mailing Address - Fax:904-381-8861
Practice Address - Street 1:700 DAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-5504
Practice Address - Country:US
Practice Address - Phone:904-381-8962
Practice Address - Fax:904-381-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9068385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691302498Medicaid
FL691302496Medicaid
FL692088800Medicaid