Healthcare Provider Details

I. General information

NPI: 1023881323
Provider Name (Legal Business Name): GLORYVE PADILLA RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204-4748
US

IV. Provider business mailing address

12911 SPRING RAIN RD
JACKSONVILLE FL
32258-5201
US

V. Phone/Fax

Practice location:
  • Phone: 904-308-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND7590
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: