Provider Demographics
NPI:1861263147
Name:JOHN KNOX VILLAGE OF CENTRAL FLORIDA, INC
Entity type:Organization
Organization Name:JOHN KNOX VILLAGE OF CENTRAL FLORIDA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:386-775-3840
Mailing Address - Street 1:101 NORTHLAKE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-6167
Mailing Address - Country:US
Mailing Address - Phone:386-775-3840
Mailing Address - Fax:
Practice Address - Street 1:701 MONASTERY RD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-6222
Practice Address - Country:US
Practice Address - Phone:386-456-1500
Practice Address - Fax:386-456-1550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN KNOX VILLAGE OF CENTRAL FLORIDA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-15
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty