MEDICARE: TAKIM HENRY DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	35734	FL

General Provider Information

NPI Number	:	1437751781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAKIM HENRY DPT

Provider Business Mailing Address
First Line	:	11705 SAN JOSE BLVD STE 111
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-1653
Country	:	US
Telephone Number	:	904-345-7450
Fax Number	:

Provider Business Practice Location Address
First Line	:	11705 SAN JOSE BLVD STE 111
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-1653
Country	:	US
Telephone Number	:	904-345-7450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2020
Last Update Date	:	12/01/2020

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