| Contacts | Authorizing Official | Update | Profile Change Request | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3866241054-2718 | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3866241054 | 2/8/2023 10:01 AM |
| Details | State | Update | | To Be Terminated | Terminated | 4/1/2021 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 9/15/2020 12:00:00 AM | 2/3/2021 11:27 AM |
| Details | State | Update | Recertification | Active | To Be Terminated | 2/3/2021 11:27 AM |
| Terminations | Termination Comments | Update | Recertification | | Consolidated site services into existing site in Deland | 2/3/2021 11:27 AM |
| Terminations | Termination Date | Update | Recertification | | 4/1/2021 12:00:00 AM | 2/3/2021 11:27 AM |
| Terminations | Termination Effective Date | Update | Recertification | | 9/15/2020 12:00:00 AM | 2/3/2021 11:27 AM |
| Terminations | Termination Reason | Update | Recertification | | Site closure | 2/3/2021 11:27 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 8/12/2020 7:52 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955102 | 8/12/2020 7:52 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 8/12/2020 7:52 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 8/12/2020 7:52 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955103 | 8/12/2020 7:52 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 8/12/2020 7:52 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1407026016 | 8/12/2020 7:52 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | FL | 8/12/2020 7:52 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1992792311 ( ) | | 8/12/2020 7:52 AM |
| Contacts | Primary Contact | Update | Change Request | Hall, Debbie
Director of Operations
NEFHS
3862026025-2705 | Valdez, Hipolito
CFO
Family Health Source
3864149601 | 8/12/2020 7:52 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3862026025-2718 | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3866241054-2718 | 8/11/2020 3:22 PM |
| Addresses | Shipping Address | Insert | Recertification | | NORTHEAST FLORIDA HEALTH SERVICES, INC.
1205 S Woodland BLVD
DELAND, FL 32720-3272 | 2/3/2020 11:18 AM |
| Addresses | Billing Address | Update | Recertification | NORTHEAST FLORIDA HEALTH SERVICES, INC.
1015 North Stone Street
Deland, FL 32720 | NORTHEAST FLORIDA HEALTH SERVICES, INC.
1205 S Woodland BLVD
Deland, FL 32720 | 2/3/2020 11:18 AM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2019 9:14:53 AM | 2/3/2020 11:18:41 AM | 2/3/2020 11:18 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3862026025 | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3862026025-2718 | 1/30/2020 9:37 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1992792311 | 1/31/2019 9:14 AM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2018 9:50:20 AM | 1/31/2019 9:14:53 AM | 1/31/2019 9:14 AM |
| Addresses | Billing Address | Update | Recertification | NORTHEAST FLORIDA HEALTH SERVICES, INC. - DBA DELAND MEDICAL CENTER
1015 North Stone Street
Deland, FL 32720 | NORTHEAST FLORIDA HEALTH SERVICES, INC.
1015 North Stone Street
Deland, FL 32720 | 2/15/2018 9:50 AM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2017 12:00:00 AM | 2/15/2018 9:50:20 AM | 2/15/2018 9:50 AM |
| Contacts | Primary Contact | Update | Recertification | Asbury, Laurie
CEO
3867499449-2118 | Hall, Debbie
Director of Operations
NEFHS
3862026025-2705 | 2/15/2018 9:50 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Asbury, Laurie
CEO
3867499449-2118 | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3862026025 | 2/12/2018 11:11 AM |
| Contacts | Authorizing Official | Update | | WILKES, KATHY
CEO
3867499449-2118 | Asbury, Laurie
CEO
3867499449-2118 | 4/25/2017 12:12 PM |
| Contacts | Primary Contact | Update | | WILKES, KATHY
CEO
3867499449-2118 | Asbury, Laurie
CEO
3867499449-2118 | 4/25/2017 12:12 PM |
| Addresses | Main Address | Insert | | |
844 W.PLYMOUTH AVENUE
DELAND, FL 32720-3284 | 2/15/2017 3:47 PM |
| Addresses | Billing Address | Insert | | | NORTHEAST FLORIDA HEALTH SERVICES, INC. - DBA DELAND MEDICAL CENTER
1015 North Stone Street
Deland, FL 32720 | 2/15/2017 3:47 PM |
| Details | Last Recertification Date | Update | | 2/12/2016 12:00:00 AM | 2/15/2017 12:00:00 AM | 2/15/2017 3:47 PM |
| Details | Last Recertification Date | Update | | 3/9/2015 12:00:00 AM | 2/12/2016 12:00:00 AM | 2/12/2016 8:57 AM |
| Details | Last Recertification Date | Update | | 3/7/2014 12:00:00 AM | 3/9/2015 12:00:00 AM | 3/9/2015 10:23 AM |
| Contacts | Authorizing Official | Insert | | | WILKES, KATHY
CEO
3867499449-2118 | 3/6/2015 1:30 PM |
| Contacts | Primary Contact | Insert | | | WILKES, KATHY
CEO
3867499449-2118 | 3/6/2015 1:30 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/7/2014 12:00:00 AM | 3/7/2014 12:56 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/27/2013 3:17 PM |
| Details | Entity Subname | Update | | DBA DELAND MEDICAL CENTER | DBA DELAND Family Health Source | 12/18/2012 2:40 PM |
| Details | Last Recertification Date | Insert | | | | 2/10/2011 11:21 AM |
| Details | Grant Number | Insert | | | H80CS02520 | 2/10/2011 11:21 AM |
| Details | 340B ID | Insert | | | CH042377A | 2/10/2011 11:21 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 2/10/2011 11:21 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 2/10/2011 11:21 AM |
| Details | Medicare Provider Number | Insert | | | | 2/10/2011 11:21 AM |
| Details | Entity Name | Insert | | | NORTHEAST FLORIDA HEALTH SERVICES, INC. | 2/10/2011 11:21 AM |
| Details | Program Code | Insert | | | CH | 2/10/2011 11:21 AM |
| Details | Entity Subname | Insert | | | DBA DELAND MEDICAL CENTER | 2/10/2011 11:21 AM |
| Dates | Participating Approval Date | Insert | | | 5/22/2008 12:00:00 AM | 2/10/2011 11:21 AM |
| Details | State | Insert | | | Active | 2/10/2011 11:21 AM |
| Dates | Registration Date | Insert | | | 5/20/2008 12:00:00 AM | 2/10/2011 11:21 AM |
| Dates | Signed By Date | Insert | | | | 2/10/2011 11:21 AM |
| Dates | Start Date | Insert | | | 7/1/2008 12:00:00 AM | 2/10/2011 11:21 AM |
| Terminations | Termination Comments | Insert | | | | 2/10/2011 11:21 AM |
| Terminations | Termination Date | Insert | | | | 2/10/2011 11:21 AM |
| Terminations | Termination Effective Date | Insert | | | | 2/10/2011 11:21 AM |
| Terminations | Termination Reason | Insert | | | | 2/10/2011 11:21 AM |