Healthcare Provider Details

I. General information

NPI: 1467834986
Provider Name (Legal Business Name): LAUREN SURDYKE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2015
Last Update Date: 06/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14286 BEACH BLVD STE 34
JACKSONVILLE FL
32250-1570
US

IV. Provider business mailing address

1588 RIVERTRACE DR
ORANGE PARK FL
32003-7777
US

V. Phone/Fax

Practice location:
  • Phone: 904-345-7510
  • Fax: 904-345-7540
Mailing address:
  • Phone: 904-710-5044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30389
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: