Provider Demographics
NPI:1699487678
Name:904 HEALTH, INC
Entity type:Organization
Organization Name:904 HEALTH, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-650-2158
Mailing Address - Street 1:221 N HOGAN ST STE 118
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-4201
Mailing Address - Country:US
Mailing Address - Phone:904-659-2475
Mailing Address - Fax:904-453-8600
Practice Address - Street 1:96040 LOFTON SQUARE CT
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6347
Practice Address - Country:US
Practice Address - Phone:904-659-2475
Practice Address - Fax:904-453-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-21
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service