Provider Demographics
NPI:1215064126
Name:ST. JOHNS RIVER RURAL HEALTH NETWORK
Entity type:Organization
Organization Name:ST. JOHNS RIVER RURAL HEALTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BILELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-723-2162
Mailing Address - Street 1:644 CESERY BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-7165
Mailing Address - Country:US
Mailing Address - Phone:904-723-2162
Mailing Address - Fax:904-723-2170
Practice Address - Street 1:644 CESERY BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-7116
Practice Address - Country:US
Practice Address - Phone:904-723-2162
Practice Address - Fax:904-723-2170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL914321100Medicaid