Provider Demographics
NPI:1417494485
Name:EISENHOWER JACKSONVILLE GROUP LLC
Entity type:Organization
Organization Name:EISENHOWER JACKSONVILLE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:734-677-0070
Mailing Address - Street 1:2671 HUFFMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4056
Mailing Address - Country:US
Mailing Address - Phone:734-677-0070
Mailing Address - Fax:734-677-0890
Practice Address - Street 1:2671 HUFFMAN BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4056
Practice Address - Country:US
Practice Address - Phone:734-677-0070
Practice Address - Fax:734-677-0890
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MORIAH INCOORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-27
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury MedicineGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1558544130OtherTRANSITIONAL LIVING FACILITY