FL Department of Health

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

FL DEPARTMENT OF HEALTH

Doing business as

Duval County Health Department

Practice address

1736 University Blvd S
Jacksonville, FL 32216-8929

Phone

(904) 253-1100

Fax

(904) 727-6548

NPI assigned

Jul 5, 2012

Organization subpart

Yes

Parent organization

FLORIDA DEPARTMENT OF HEALTHAs reported in NPPES

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

Authorized official

Name

Dr. Kelli T Wells, M.D.

Title

Director

Phone

(904) 253-2062

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Duval County Health Department Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Federally qualified health center certification: CCN 101052

Legal name

SOUTH JACKSONVILLE FAMILY HEALTH CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Aug 1, 2009

Last certification

Aug 1, 2009

Ownership / control type

For profit – corporation

Facility address

1736 University Boulevard South
Jacksonville, FL 32216

Part of

Dept of Health Central Pharmacy

Locations

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

{
    "created_epoch": "1341446400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1376438400000",
    "number": "1497010425",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "900 UNIVERSITY BLVD N",
            "address_2": "MC-75",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322119230",
            "telephone_number": "904-253-2062",
            "fax_number": "904-253-1942"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1736 UNIVERSITY BLVD S",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322168929",
            "telephone_number": "904-253-1100",
            "fax_number": "904-727-6548"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FL DEPARTMENT OF HEALTH",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FLORIDA DEPARTMENT OF HEALTH",
        "enumeration_date": "2012-07-05",
        "last_updated": "2013-08-14",
        "status": "A",
        "authorized_official_last_name": "WELLS",
        "authorized_official_first_name": "KELLI",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "904-253-2062",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "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": "6905561-02",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6905561-03",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Duval County Health Department",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Federally Qualified Health Center (FQHC) in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Federally Qualified Health Center (FQHC) in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.