Healthcare Provider Details

I. General information

NPI: 1477830453
Provider Name (Legal Business Name): RTA HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5222 LENOX AVE
JACKSONVILLE FL
32205-4838
US

IV. Provider business mailing address

PO BOX 49307
JACKSONVILLE BEACH FL
32240-9307
US

V. Phone/Fax

Practice location:
  • Phone: 904-783-0008
  • Fax:
Mailing address:
  • Phone: 904-994-4833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1477830453
License Number StateFL

VIII. Authorized Official

Name: MRS. ADRIANA MCCLERREN
Title or Position: ADMINISTRATOR
Credential:
Phone: 904-994-4833