Provider Demographics
NPI:1104259019
Name:FLORIDA DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:T
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-253-2062
Mailing Address - Street 1:900 UNIVERSITY BLVD N
Mailing Address - Street 2:MC-75
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-9230
Mailing Address - Country:US
Mailing Address - Phone:904-253-2062
Mailing Address - Fax:904-253-1942
Practice Address - Street 1:5150 TIMUQUANA RD
Practice Address - Street 2:SUITE 9
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-8959
Practice Address - Country:US
Practice Address - Phone:904-253-1120
Practice Address - Fax:904-253-2514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6905561-05Medicaid
FL6905561-08Medicaid
FL6905561-05Medicaid