Provider Demographics
NPI:1457609984
Name:RIVER GARDEN HEBREW HOME FOR THE AGED
Entity Type:Organization
Organization Name:RIVER GARDEN HEBREW HOME FOR THE AGED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-886-8409
Mailing Address - Street 1:11401 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1402
Mailing Address - Country:US
Mailing Address - Phone:904-886-8409
Mailing Address - Fax:904-880-2968
Practice Address - Street 1:11401 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1402
Practice Address - Country:US
Practice Address - Phone:904-886-8409
Practice Address - Fax:904-880-2968
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER GARDEN HEBREW HOME FOR THE AGED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-15
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHHA299991334251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health