Basic Information
| Provider Information | |||||||||
| NPI: | 1659557817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NURSING HOME ASSOCIATES OF JACKSONVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7756 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529851371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1717 CHERRY CIR | ||||||||
| Address2: | |||||||||
| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362076810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564534383 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | DOWNEY | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 2562381100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1093908618 | 01 | AL | DOWNEY NPI # | OTHER |