Provider Demographics
NPI:1730188673
Name:CITY OF JACKSONVILLE
Entity type:Organization
Organization Name:CITY OF JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAYOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-435-7611
Mailing Address - Street 1:320 CHURCH AVE SE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-2651
Mailing Address - Country:US
Mailing Address - Phone:256-435-7611
Mailing Address - Fax:256-435-4103
Practice Address - Street 1:506 CHINABEE AVE SE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265-2881
Practice Address - Country:US
Practice Address - Phone:256-435-7611
Practice Address - Fax:256-435-4103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0402813416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL200008103Medicaid
AL000052173Medicare Oscar/Certification