Healthcare Provider Details

I. General information

NPI: 1407031750
Provider Name (Legal Business Name): SHIRO IWAE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 PENMAN RD SUITE C
JACKSONVILLE BEACH FL
32250
US

IV. Provider business mailing address

1653 LINKSIDE CT N
ATLANTIC BEACH FL
32233
US

V. Phone/Fax

Practice location:
  • Phone: 904-241-9500
  • Fax: 904-241-2009
Mailing address:
  • Phone: 904-241-9500
  • Fax: 904-241-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT10623
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: