Provider Demographics
NPI:1336959840
Name:ELLIS-MOORE CORPORATION
Entity type:Organization
Organization Name:ELLIS-MOORE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JONI
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, CCRN
Authorized Official - Phone:904-710-0437
Mailing Address - Street 1:3901 UNIVERSITY BLVD S STE 125
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4375
Mailing Address - Country:US
Mailing Address - Phone:904-710-0437
Mailing Address - Fax:904-475-2706
Practice Address - Street 1:7207 GOLDEN WINGS RD STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-3324
Practice Address - Country:US
Practice Address - Phone:904-710-0437
Practice Address - Fax:904-475-2706
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIS-MOORE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019233500Medicaid