| Details | Last Recertification Date | Update | Recertification | 2/15/2024 12:54:07 PM | 2/20/2025 6:05:38 PM | 2/20/2025 6:05 PM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2023 7:30:43 AM | 2/15/2024 12:54:07 PM | 2/15/2024 12:54 PM |
| Addresses | Main Address | Update | Recertification |
1205 S Woodland Blvd
Suite 4 & 5
Deland, FL 32720-7466 |
1205 S Woodland Blvd
Suite 3
Deland, FL 32720-7466 | 2/9/2023 7:30 AM |
| Details | Last Recertification Date | Update | Recertification | 2/18/2022 10:19:49 AM | 2/9/2023 7:30:43 AM | 2/9/2023 7:30 AM |
| 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 |
| Contacts | Signed By | 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 | Last Recertification Date | Update | Recertification | 2/3/2021 10:24:47 AM | 2/18/2022 10:19:49 AM | 2/18/2022 10:19 AM |
| Addresses | Main Address | Update | Change Request |
1205 S Woodland Blvd
Suite 5
Deland, FL 32720-7466 |
1205 S Woodland Blvd
Suite 4 & 5
Deland, FL 32720-7466 | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955102 | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955103 | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955106 | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955107 | 7/27/2021 7:15 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 7/27/2021 7:15 AM |
| Addresses | Shipping Address | Delete | Recertification | Northeast Florida Health Services Inc, dba Family Health Source
1205 South Woodland Boulevard
Suite 5
Deland, FL 32720 | | 2/3/2021 10:24 AM |
| Addresses | Main Address | Update | Recertification |
1205 S Woodland Blvd
Deland, FL 32720-7466 |
1205 S Woodland Blvd
Suite 5
Deland, FL 32720-7466 | 2/3/2021 10:24 AM |
| Addresses | Billing Address | Update | Recertification | Northeast Florida Health Services Inc, dba Family Health Source
1205 South Woodland Boulevard
Suite 5
Deland, FL 32270 | Northeast Florida Health Services Inc, dba Family Health Source
1205 South Woodland Boulevard
Suite 3
Deland, FL 32270 | 2/3/2021 10:24 AM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2020 5:04:55 PM | 2/3/2021 10:24:47 AM | 2/3/2021 10:24 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955117 | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955118 | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 687955108 | 8/12/2020 7:50 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 8/12/2020 7:50 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1467907626 | 8/12/2020 7:50 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | FL | 8/12/2020 7:50 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1063903672 | 8/12/2020 7:50 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | FL | 8/12/2020 7:50 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1992792311 ( ) | | 8/12/2020 7:50 AM |
| Contacts | Primary Contact | Update | Change Request | greenhouse, charles b
Director of Pharmacy
northeast florida health services, inc
3868884912 | Moll, Michelle
Pharmacy Director
Family Health Center
3868884912 | 8/12/2020 7:50 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 |
| Contacts | Signed By | 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 |
| Details | Last Recertification Date | Update | Recertification | 1/31/2019 9:13:47 AM | 2/3/2020 5:04:55 PM | 2/3/2020 5:04 PM |
| 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 |
| Contacts | Signed By | 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 | Medicaid: Is Primary | Insert | Change Request | | False | 7/31/2019 2:35 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 102004200 | 7/31/2019 2:35 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 7/31/2019 2:35 PM |
| Contacts | Primary Contact | Update | Change Request | Hall, Deborah
Director of Operations
Northeast Florida Health Services
3862026025-2705 | greenhouse, charles b
Director of Pharmacy
northeast florida health services, inc
3868884912 | 7/31/2019 2:35 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1992792311 | 1/31/2019 9:13 AM |
| Details | Last Recertification Date | Update | Recertification | | 1/31/2019 9:13:47 AM | 1/31/2019 9:13 AM |
| Details | State | Update | | Approved | Active | 10/1/2018 12:05 AM |
| Addresses | Main Address | Update | OPA Edit |
Deland, FL 32720-7466 |
1205 S Woodland Blvd
Deland, FL 32720-7466 | 9/5/2018 10:20 AM |
| Addresses | Billing Address | Insert | New Registration | | Northeast Florida Health Services Inc, dba Family Health Source
1205 South Woodland Boulevard
Suite 5
Deland, FL 32270 | 9/5/2018 10:17 AM |
| Contacts | Signed By | Insert | New Registration | | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3862026025 | 9/5/2018 10:17 AM |
| Details | 340B ID | Update | New Registration | | CH042377E | 9/5/2018 10:17 AM |
| Dates | Participating Approval Date | Update | New Registration | | 9/5/2018 10:17:33 AM | 9/5/2018 10:17 AM |
| Details | State | Update | New Registration | Pending | Approved | 9/5/2018 10:17 AM |
| Dates | Signed By Date | Update | New Registration | | 8/27/2018 2:51:49 PM | 9/5/2018 10:17 AM |
| Dates | Start Date | Update | New Registration | | 10/1/2018 12:00:00 AM | 9/5/2018 10:17 AM |
| Addresses | Main Address | Insert | New Registration | |
Deland, FL 32720-7466 | 8/6/2018 5:35 PM |
| Addresses | Billing Address | Insert | New Registration | | Northeast Florida Health Services Inc, dba Family Health Source
1205 South Woodland Boulevard
Suite 5
Deland, FL 32270 | 8/6/2018 5:35 PM |
| Addresses | Shipping Address | Insert | New Registration | | Northeast Florida Health Services Inc, dba Family Health Source
1205 South Woodland Boulevard
Suite 5
Deland, FL 32720 | 8/6/2018 5:35 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Asbury, Laurie
CEO
Northeast Florida Health Services, inc,
3862026025 | 8/6/2018 5:35 PM |
| Contacts | Primary Contact | Insert | New Registration | | Hall, Deborah
Director of Operations
Northeast Florida Health Services
3862026025-2705 | 8/6/2018 5:35 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Details | Grant Number | Insert | New Registration | | H80CS02520 | 8/6/2018 5:35 PM |
| Details | 340B ID | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Details | Medicare Provider Number | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Details | Entity Name | Insert | New Registration | | Northeast Florida Health Services Inc | 8/6/2018 5:35 PM |
| Details | Program Code | Insert | New Registration | | CH | 8/6/2018 5:35 PM |
| Details | Entity Subname | Insert | New Registration | | Family Health Source | 8/6/2018 5:35 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Details | State | Insert | New Registration | | Pending | 8/6/2018 5:35 PM |
| Dates | Registration Date | Insert | New Registration | | 8/6/2018 5:35:39 PM | 8/6/2018 5:35 PM |
| Dates | Signed By Date | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Dates | Start Date | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Terminations | Termination Date | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 8/6/2018 5:35 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 8/6/2018 5:35 PM |