Basic Information
| Provider Information | |||||||||
| NPI: | 1487772216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALACHUA COUNTY ORGANIZATION FOR RURAL NEEDS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACORN CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3123 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Practice Location | |||||||||
| Address1: | 23320 N STATE ROAD 235 | ||||||||
| Address2: | |||||||||
| City: | BROOKER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326225266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524851133 | ||||||||
| FaxNumber: | 3524852927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | CANDICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3524851133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 98392 | 01 | FL | FLORIDA BLUE | OTHER | 060245101 | 05 | FL | MEDICAID |