Basic Information
| Provider Information | |||||||||
| NPI: | 1265585806 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE NEMOURS FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEMOURS CHILDREN'S SPECIALTY CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10140 CENTURION PARKWAY N | ||||||||
| Address2: | C/O MANAGED CARE | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560532 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 807 CHILDRENS WAY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043903600 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCKENDREE | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9046975628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE NEMOURS FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QE0700X | N | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment | 261QG0250X | N | Ambulatory Health Care Facilities | Clinic/Center | Genetics | 261QH0700X | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Research | 261QU0200X | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QX0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Oncology | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 061950729 | 05 | FL | MEDICAID | 061950721 | 05 | FL | MEDICAID |