Provider Demographics
NPI:1316105091
Name:DANIEL MEMORIAL INC
Entity type:Organization
Organization Name:DANIEL MEMORIAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-296-1055
Mailing Address - Street 1:3725 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5813
Mailing Address - Country:US
Mailing Address - Phone:904-296-1055
Mailing Address - Fax:904-448-7700
Practice Address - Street 1:3725 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5813
Practice Address - Country:US
Practice Address - Phone:904-296-1055
Practice Address - Fax:904-448-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4894251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075421800Medicaid