Basic Information
| Provider Information | |||||||||
| NPI: | 1962690297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLETCHER'S TENDERCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6851 DISTRIBUTION AVE S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322562742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043874481 | ||||||||
| FaxNumber: | 8663817235 | ||||||||
| Practice Location | |||||||||
| Address1: | 1934 BEACHWAY RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322072320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048589797 | ||||||||
| FaxNumber: | 9048589719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2007 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | FLETCHER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9043874481 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3140N1450X | 60080967 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 240001400 | 05 | FL | MEDICAID |