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4856 First Coast Hwy Ste 1 Fernandina Beach FL 32034-5495 | |
| (904) 229-5038 | |
| (904) 592-5343 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 4856 First Coast Hwy Ste 1, Fernandina Beach, Florida |
| Authorized Official Name and Position | Gregory Devon Miller (OWNER) |
| Authorized Official Contact | 9042295038 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4856 First Coast Hwy Ste 1 Fernandina Beach FL 32034-5495 Ph: (904) 229-5038 | 4856 First Coast Hwy Ste 1 Fernandina Beach FL 32034-5495 Ph: (904) 229-5038 |
| NPI Number | 1902436975 |
|---|---|
| Provider Enumeration Date | 01/18/2020 |
| Last Update Date | 03/27/2023 |
| Certification Date | 03/27/2023 |
| Medicare PECOS PAC ID | 2466887187 |
|---|---|
| Medicare Enrollment ID | O20200127000503 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1902436975 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0850X | Clinic/center - Adult Mental Health | (* (Not Available)) | Primary |
| Provider Name | Gregory Devon Miller |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1427317825 PECOS PAC ID: 9335366186 Enrollment ID: I20160629000056 |
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