Healthcare Provider Details

I. General information

NPI: 1679878904
Provider Name (Legal Business Name): IDEAL IMAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4866 BIG ISLAND DR STE #5
JACKSONVILLE FL
32246-7498
US

IV. Provider business mailing address

4866 BIG ISLAND DR STE #5
JACKSONVILLE FL
32246-7498
US

V. Phone/Fax

Practice location:
  • Phone: 904-652-0652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9193543
License Number StateFL

VIII. Authorized Official

Name: DR. RICHARD DEAN GLASSMAN
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 904-652-0652