Healthcare Provider Details

I. General information

NPI: 1871314484
Provider Name (Legal Business Name): ANDREA CAROLINA SALOM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14534 OLD SAINT AUGUSTINE RD STE 3330
JACKSONVILLE FL
32258-2646
US

IV. Provider business mailing address

10033 CHESTER LAKE RD E
JACKSONVILLE FL
32256-3461
US

V. Phone/Fax

Practice location:
  • Phone: 904-292-1808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number42304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: