Healthcare Provider Details

I. General information

NPI: 1871008094
Provider Name (Legal Business Name): LETARA REYONA MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REYONA STILES

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 WHITMAN ST
JACKSONVILLE FL
32210-1237
US

IV. Provider business mailing address

1745 WHITMAN ST
JACKSONVILLE FL
32210-1237
US

V. Phone/Fax

Practice location:
  • Phone: 904-424-8590
  • Fax:
Mailing address:
  • Phone: 904-424-8590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: