Provider Demographics
NPI:1649451295
Name:JAX'S FAMILY CARE AND RESEARCH CENTER, P.A.
Entity type:Organization
Organization Name:JAX'S FAMILY CARE AND RESEARCH CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAIRO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:DE LA HOZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:BBA
Authorized Official - Phone:904-425-6963
Mailing Address - Street 1:5233 RICKER RD STE 101
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5233 RICKER RD STE 101
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1148
Practice Address - Country:US
Practice Address - Phone:904-425-6963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70797261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31309XMedicare PIN