Provider Demographics
NPI:1063898864
Name:WEST JAX SKILLED NURSING
Entity type:Organization
Organization Name:WEST JAX SKILLED NURSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:SHARPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-783-2405
Mailing Address - Street 1:100 CYPRESS LAGOON CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2106
Mailing Address - Country:US
Mailing Address - Phone:904-783-2405
Mailing Address - Fax:904-786-4981
Practice Address - Street 1:100 CYPRESS LAGOON CT
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2106
Practice Address - Country:US
Practice Address - Phone:904-783-2405
Practice Address - Fax:904-786-4981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1285048280207Q00000X
FL1750382669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620455400Medicaid
FL620455400Medicaid