Basic Information
| Provider Information | |||||||||
| NPI: | 1417494485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EISENHOWER JACKSONVILLE GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2671 HUFFMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322464056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346770070 | ||||||||
| FaxNumber: | 7346770890 | ||||||||
| Practice Location | |||||||||
| Address1: | 2671 HUFFMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322464056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346770070 | ||||||||
| FaxNumber: | 7346770890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2017 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | PENDLEY | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7346770070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MORIAH INCOORPORATED | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSN | ||||||||
| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P0301X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | 251B00000X | N | Agencies | Case Management | 251S00000X | N | Agencies | Community/Behavioral Health | 320600000X | N | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | 320700000X | N | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities | 320800000X | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320900000X | N | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 323P00000X | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1558544130 | 01 | FL | TRANSITIONAL LIVING FACILITY | OTHER |