Healthcare Provider Details

I. General information

NPI: 1649748815
Provider Name (Legal Business Name): MR. TROY MAHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 3RD ST S
JACKSONVILLE BEACH FL
32250-5848
US

IV. Provider business mailing address

4006 3RD ST S
JACKSONVILLE BEACH FL
32250-5848
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-4327
  • Fax: 904-247-4328
Mailing address:
  • Phone: 904-247-4327
  • Fax: 904-247-4328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS2210
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: