NPIMap

Organization Active NPI

Im Sulzbacher Center for the Homeless Inc

  • Federally Qualified Health Center (FQHC)
  • Jacksonville Beach, FL
National Provider Identifier
1326312315
Registry record updated Nov 19, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
686032002 Issued in FL
Legal business name
IM SULZBACHER CENTER FOR THE HOMELESS INC
Practice address
850 6TH Ave S Ste 500
Jacksonville Beach, FL 32250-4200
Phone
(904) 224-3550
NPI assigned
Mar 8, 2012
Organization subpart
Yes
Parent organization
IM SULZBACHER CENTER FOR THE HOMELESS INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 19, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Kathleen Patneau
Title
Health Services Administrator
Phone
(904) 394-8056

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 686032002 FL Primary

Addresses

Primary practice location

850 6TH Ave S Ste 500
Jacksonville Beach, FL 32250-4200

Mailing address

611 E Adams St
Jacksonville, FL 32202-2847

Other identifiers 1

IdentifierTypeStateIssuer
686032002MedicaidFL

Other names 1

  • Beaches Community Healthcare Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20121130000567 FL Part A Provider - Federally Qualified Health Center (FQHC) 2860652641 Practice locations: Jacksonville Beach, FL

Federally qualified health center certification: CCN 101116

Legal name
IM SULZBACHER CENTER FOR THE HOMELESS, INC
Doing business as
BEACHES COMMUNITY HEALTHCARE' A SULZABACHER CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 30, 2012
Last certification
Nov 30, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 9, 1994 in FL
Enrollment address
850 Sixth Avenue S, Ste 500
Jacksonville Beach, FL 32250-4200

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Im Sulzbacher Center for the Homeless Inc2 organizations share this tax ID, including this one
Part of
Im Sulzbacher Center for the Homeless Inc

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Cindy Funkhouser Individual Corporate OfficerCeo Sep 6, 2012
W-2 Managing EmployeeCeo Sep 6, 2012
Operational/Managerial ControlCeo Sep 6, 2012
Im Sulzbacher Center for the Homeless, Inc Organization, Jacksonville, FL Corporation, Non-profit 5% Or Greater Direct Ownership Interest Mar 9, 1994
Brenda March Individual Corporate OfficerCfo Nov 27, 2017
W-2 Managing EmployeeCfo Nov 27, 2017
Operational/Managerial ControlCfo Nov 27, 2017
Heather Morris Individual Corporate DirectorAssistant Director, Clinic Operatio Aug 31, 2017

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
The Sulzbacher CenterJacksonville, FL, CCN 101096 Federally qualified health center 5% Or Greater Direct Ownership Interest Mar 9, 1994

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1331164800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1353283200000",
    "number": "1326312315",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "611 E ADAMS ST",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322022847"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "850 6TH AVE S STE 500",
            "city": "JACKSONVILLE BEACH",
            "state": "FL",
            "postal_code": "322504200",
            "telephone_number": "904-224-3550"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IM SULZBACHER CENTER FOR THE HOMELESS INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "IM SULZBACHER CENTER FOR THE HOMELESS INC",
        "enumeration_date": "2012-03-08",
        "last_updated": "2012-11-19",
        "status": "A",
        "authorized_official_last_name": "PATNEAU",
        "authorized_official_first_name": "KATHLEEN",
        "authorized_official_title_or_position": "HEALTH SERVICES ADMINISTRATOR",
        "authorized_official_telephone_number": "904-394-8056",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "FL",
            "license": "686032002",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "686032002",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beaches Community Healthcare",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville Beach, FL

Sources for this page

Verify at the official NPI Registry.