Provider Demographics
NPI:1124533948
Name:LARUE ESTATES
Entity type:Organization
Organization Name:LARUE ESTATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-370-3575
Mailing Address - Street 1:8426 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-2841
Mailing Address - Country:US
Mailing Address - Phone:904-370-3575
Mailing Address - Fax:904-683-0147
Practice Address - Street 1:8426 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-2841
Practice Address - Country:US
Practice Address - Phone:904-370-3575
Practice Address - Fax:904-683-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 253Z00000X, 320800000X, 385HR2060X, 251E00000X
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1508222076Medicaid