Healthcare Provider Details

I. General information

NPI: 1043781495
Provider Name (Legal Business Name): JOHN REID
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9439 SAN JOSE BLVD APT 76
JACKSONVILLE FL
32257-5523
US

IV. Provider business mailing address

9439 SAN JOSE BLVD APT 76
JACKSONVILLE FL
32257-5523
US

V. Phone/Fax

Practice location:
  • Phone: 904-426-2833
  • Fax:
Mailing address:
  • Phone: 904-426-2833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberR300478613700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: