Basic Information
| Provider Information | |||||||||
| NPI: | 1083384861 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOLANTIC OF JACKSONVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 EASTPARK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156004100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1544 COUNTY ROAD 220 # 100 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048309009 | ||||||||
| FaxNumber: | 9048728412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2021 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | MANNING | ||||||||
| AuthorizedOfficialFirstName: | SIERRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9049005436 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.