Provider Demographics
NPI:1063903672
Name:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-202-6025
Mailing Address - Street 1:1205 S WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7466
Mailing Address - Country:US
Mailing Address - Phone:386-202-6025
Mailing Address - Fax:386-269-1847
Practice Address - Street 1:1205 S WOODLAND BLVD STE 5
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7464
Practice Address - Country:US
Practice Address - Phone:386-202-6025
Practice Address - Fax:386-269-1847
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-21
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102004200Medicaid