Healthcare Provider Details

I. General information

NPI: 1417192022
Provider Name (Legal Business Name): IPS OF JACKSONVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4754 E STATE ROAD 64
BRADENTON FL
34208-9058
US

IV. Provider business mailing address

PO BOX 864483
ORLANDO FL
32886-4483
US

V. Phone/Fax

Practice location:
  • Phone: 888-337-3509
  • Fax: 941-328-3997
Mailing address:
  • Phone: 888-337-3509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1176
License Number StateFL

VIII. Authorized Official

Name: CARL R NOBACK
Title or Position: MEMBER
Credential: MD
Phone: 941-360-1566