Provider Demographics
NPI:1932825635
Name:ST. AUGUSTINE HEALTH SYSTEM DELAWARE LLC
Entity Type:Organization
Organization Name:ST. AUGUSTINE HEALTH SYSTEM DELAWARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-703-9933
Mailing Address - Street 1:7004 SECURITY BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2534
Mailing Address - Country:US
Mailing Address - Phone:443-703-9933
Mailing Address - Fax:
Practice Address - Street 1:200 CONTINENTAL DR STE 401
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4337
Practice Address - Country:US
Practice Address - Phone:443-703-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities