Provider Demographics
NPI:1720075351
Name:SOVEREIGN HEALTHCARE OF MACCLENNY, LLC
Entity type:Organization
Organization Name:SOVEREIGN HEALTHCARE OF MACCLENNY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:R.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CRONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-574-2100
Mailing Address - Street 1:5887 GLENRIDGE DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5574
Mailing Address - Country:US
Mailing Address - Phone:404-574-2100
Mailing Address - Fax:404-574-2105
Practice Address - Street 1:755 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2685
Practice Address - Country:US
Practice Address - Phone:904-259-4873
Practice Address - Fax:904-259-5381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1222096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
V573P-6392OtherVA
FL026351600Medicaid
FL026351600Medicaid