| NPI Number | 1629604046 |
| Provider Name | Ancient City Diagnostics, Llc |
| Authorized Official | Name: Christopher Edmondson Title: Owner Phone: 904-439-3414 |
| Status | |
| Entity Type | Organization |
| Enumeration Date | 03/17/2020 |
| Last Update Date | 03/17/2020 |
| Organization Subpart | N |
| Business Practice address |
150 SOUTHPARK BLVD STE 206, Saint Augustine, 32086-5179 Florida View on Google Map |
| Business Practice phone | 904-439-3414 |
| Business Practice fax | |
| Mailing address |
8563 ARGYLE BUSINESS LOOP STE 5, Jacksonville, 32244-6613 Florida View on Google Map |
| Other phone | 904-439-3414 |
| Other fax | |
| Email Address | shannonfig@domain.com Reval Email Address |
| Field Name | Field Value |
|---|---|
| NPI | 1629604046 |
| 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. | |
| Entity Type | Organization |
Code describing the type of health care provider that is being assigned an NPI. Codes are:
|
|
| Is Organization Subpart | N |
| The "Is the organization a subpart?" question must be answered. If the organization is a subpart = , the Parent Organization Legal Business Name (LBN) and Parent Organization Taxpayer Identification Number (TIN) fields must be completed. The Parent Organization LBN and TIN fields can only be completed if the answer to the subpart question is Yes. Many organization health care providers who apply for NPIs are not legal entities themselves but are parts of other organization health care providers that are legal entities (the "parents"). Here are three examples of organization health care providers that may be considered subparts and may apply for NPIs if so directed by their "parents": (1) The psychiatric unit in a hospital is not a legal entity but is part of the hospital (the "parent"), which is a legal entity. The legal entity must obtain an NPI. The psychiatric unit is an example of a subpart that could have its own NPI if the hospital determines that it should. (2) A group practice that is not a sole proprietorship has a main location and could have other offices in different locations, but each office is not a separate legal entity; instead, each office is part of the corporation (the "parent") which is a legal entity. The offices are examples of subparts that could have their own NPIs if the main location determines that they should. (3) A pharmacy fills prescriptions for patients whose physicians have prescribed medications for them and may also rent or sell durable medical equipment to patients whose physicians have ordered such equipment for them. Neither the pharmacy line of business nor the DME line of business represent legal entities; instead, both lines of business are part of an organization (the "parent") that is a legal entity. Each line of business represents a different Healthcare Provider Taxonomy or area of specialization that often submits its own electronic claims to health plans. The "parent"-we don't know who the parent is in this example-must ensure that each subpart that submits its own claims to health plans has its own NPI. | |
| Provider Organization Name (Legal Business Name) | Ancient City Diagnostics, Llc |
| Provide organization name (legal business name used to file tax returns with the IRS). The Organization Name field allows the following special characters: ampersand, apostrophe, "at" sign, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. | |
| Provider First Line Business Mailing Address | 8563 ARGYLE BUSINESS LOOP STE 5 |
| The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''. | |
| Provider Business Mailing Address City Name | Jacksonville |
| The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''. | |
| Provider Business Mailing Address State Name | Florida |
| The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''. | |
| Provider Business Mailing Address Postal Code | 32244-6613 |
| The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''. | |
| Provider Business Mailing Address Country Code | US |
| The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''. | |
| Provider Business Mailing Address Telephone Number | 904-439-3414 |
| The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''. | |
| Provider First Line Business Practice Location Address | 150 SOUTHPARK BLVD STE 206 |
| The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. | |
| Provider Business Practice Location Address City Name | Saint Augustine |
| The city name in the location address of the provider being identified. | |
| Provider Business Practice Location Address State Name | Florida |
| The State or Province name in the location address of the provider being identified. | |
| Provider Business Practice Location Address Postal Code | 32086-5179 |
| The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. | |
| Provider Business Practice Location Address Country Code | US |
| The country code in the location address of the provider being identified. | |
| Provider Business Practice Location Address Telephone Number | 904-439-3414 |
| The telephone number associated with the location address of the provider being identified. | |
| Provider Enumeration Date | 03/17/2020 |
| The date the provider was assigned a unique identifier (assigned an NPI). | |
| Last Update Date | 03/17/2020 |
| The date that a record was last updated or changed. | |
| Authorized Official Last Name | Edmondson |
| The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. | |
| Authorized Official First Name | Christopher |
| The first name of the authorized official | |
| Authorized Official Title or Position | Owner |
| The title or position of the authorized official | |
| Authorized Official Telephone Number | 904-439-3414 |
| The 10-position telephone number of the authorized official. | |
| Healthcare Provider Taxonomy Code #1 | 291900000X |
| The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization. | |
| Healthcare Provider Taxonomy 1 | A Department of Defense (DoD) medical clinical reference laboratory not associated with a DoD Hospital or DoD Clinic. An example is the Armed Forces Institute of Pathology. |
| Healthcare Provider Taxonomy #1 | |
| Healthcare Provider Primary Taxonomy Switch 1 | Y |
Primary Taxonomy:
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