NPIMap

Organization Active NPI

Northeast Florida Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Deland, FL
National Provider Identifier
1467907626
Registry record updated Aug 10, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST FLORIDA HEALTH SERVICES, INC.
Practice address
1205 S Woodland Blvd Ste 3
Deland, FL 32720-7464
Phone
(386) 202-6025
Fax
(386) 202-1755
NPI assigned
Aug 17, 2016
Organization subpart
Yes
Parent organization
NORTHEAST FLORIDA HEALTH SERVICES, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 10, 2021

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

Authorized official

Name
Rebecca Collier
Title
Credentialing Specialist
Phone
(386) 202-6025

Specialties & licenses 1

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

Addresses

Primary practice location

1205 S Woodland Blvd Ste 3
Deland, FL 32720-7464

Mailing address

1205 S Woodland Blvd Ste 7
Deland, FL 32720-7466
Phone (386) 202-6025

Other identifiers 1

IdentifierTypeStateIssuer
687955117MedicaidFL

Other names 1

  • Family Health Source Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130814000255 FL Part A Provider - Federally Qualified Health Center (FQHC) 0547249518 2 other NPIs on this enrollment
Practice locations: Deland, FL

Federally qualified health center certification: CCN 101127

Legal name
NORTHEAST FLORIDA HEALTH SERVICES, INC
Doing business as
FAMILY HEALTH SOURCE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 14, 2013
Last certification
Aug 14, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 22, 2002 in FL
Enrollment address
1205 S Woodland Blvd, Ste 5
Deland, FL 32720-7464

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Northeast Florida Health11 organizations share this tax ID, including this one
Part of
Northeast Florida Health

Other organizations with this tax ID 10

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

Locations

1205 S Woodland Blvd
Ste 7
Deland, FL 32720

Ownership & related parties

All disclosed owners & managing parties 1

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

NameRoleSinceShare
Laurie Asbury Individual Corporate OfficerCeo Apr 1, 2013
W-2 Managing EmployeeCeo Apr 1, 2013

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Family Health SourceDeltona, FL, CCN 681156 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2020

Owned or controlled facilities with NPI records 1

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

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

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

{
    "created_epoch": "1471392000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1628553600000",
    "number": "1467907626",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1205 S WOODLAND BLVD STE 7",
            "city": "DELAND",
            "state": "FL",
            "postal_code": "327207466",
            "telephone_number": "386-202-6025",
            "fax_number": "386-269-4149"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1205 S WOODLAND BLVD STE 3",
            "city": "DELAND",
            "state": "FL",
            "postal_code": "327207464",
            "telephone_number": "386-202-6025",
            "fax_number": "386-202-1755"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST FLORIDA HEALTH SERVICES, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTHEAST FLORIDA HEALTH SERVICES, INC.",
        "enumeration_date": "2016-08-17",
        "last_updated": "2021-08-10",
        "certification_date": "2021-08-10",
        "status": "A",
        "authorized_official_last_name": "COLLIER",
        "authorized_official_first_name": "REBECCA",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "386-202-6025"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "687955117",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Health Source",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Deland, FL

Sources for this page

Verify at the official NPI Registry.