Provider Demographics
NPI:1649632951
Name:MEMORIAL FAMILY PRACTICE, LLC
Entity type:Organization
Organization Name:MEMORIAL FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHARGE ENTRY SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-702-5353
Mailing Address - Street 1:3627 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 235
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4230
Mailing Address - Country:US
Mailing Address - Phone:904-702-6353
Mailing Address - Fax:904-702-6356
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 235
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4230
Practice Address - Country:US
Practice Address - Phone:904-702-6353
Practice Address - Fax:904-702-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital