Healthcare Provider Details

I. General information

NPI: 1558738773
Provider Name (Legal Business Name): JUSTIN PODELL PT, DPT, MED, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10423 CENTURION PKWY N
JACKSONVILLE FL
32256-0527
US

IV. Provider business mailing address

10423 CENTURION PKWY N
JACKSONVILLE FL
32256-0527
US

V. Phone/Fax

Practice location:
  • Phone: 904-854-2090
  • Fax: 904-854-2093
Mailing address:
  • Phone: 904-854-2090
  • Fax: 904-854-2093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: