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4131 University Blvd S Ste 10 Jacksonville FL 32216-4346 | |
| (508) 769-2707 | |
| (401) 305-3048 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 4131 University Blvd S Ste 10, Jacksonville, Florida |
| Authorized Official Name and Position | Boris Bergus (CEOI) |
| Authorized Official Contact | 5087692707 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4131 University Blvd S Ste 10 Jacksonville FL 32216-4346 Ph: (508) 769-2707 | 4131 University Blvd S Ste 10 Jacksonville FL 32216-4346 Ph: (508) 769-2707 |
| NPI Number | 1609591361 |
|---|---|
| Provider Enumeration Date | 10/05/2022 |
| Last Update Date | 08/28/2023 |
| Certification Date | 08/28/2023 |
| Medicare PECOS PAC ID | 1658725320 |
|---|---|
| Medicare Enrollment ID | O20230928002640 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609591361 | NPI | - | NPPES |
| Provider Name | Chadd K Eaglin |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1750599833 PECOS PAC ID: 9032381181 Enrollment ID: I20160225002528 |
| Provider Name | John Watts |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1275886236 PECOS PAC ID: 3971881509 Enrollment ID: I20161101002266 |
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