Provider Demographics
NPI:1750787131
Name:MS JACKSONVILLE SH, LLC
Entity type:Organization
Organization Name:MS JACKSONVILLE SH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'HARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-332-0774
Mailing Address - Street 1:4870 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:904-332-0774
Mailing Address - Fax:904-332-0775
Practice Address - Street 1:4870 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6004
Practice Address - Country:US
Practice Address - Phone:904-332-0774
Practice Address - Fax:904-332-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11689310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility