Healthcare Provider Details

I. General information

NPI: 1003894387
Provider Name (Legal Business Name): RAZEL B. ICBAN PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3937 SPRING PARK RD
JACKSONVILLE FL
32207-5739
US

IV. Provider business mailing address

9318 OSTERLEY CT
JACKSONVILLE FL
32244-7134
US

V. Phone/Fax

Practice location:
  • Phone: 904-737-6777
  • Fax:
Mailing address:
  • Phone: 904-207-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6377
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: