Healthcare Provider Details

I. General information

NPI: 1245490796
Provider Name (Legal Business Name): MR. ROELL T MILBRY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 SOUTHSIDE BLVD APT 313
JACKSONVILLE FL
32256-8478
US

IV. Provider business mailing address

PO BOX 23277
JACKSONVILLE FL
32241-3277
US

V. Phone/Fax

Practice location:
  • Phone: 904-982-2407
  • Fax:
Mailing address:
  • Phone: 904-982-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: