Healthcare Provider Details

I. General information

NPI: 1063191088
Provider Name (Legal Business Name): ORION LIGHTLY CRPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 STOCKTON ST
JACKSONVILLE FL
32204-2534
US

IV. Provider business mailing address

555 STOCKTON ST
JACKSONVILLE FL
32204-2534
US

V. Phone/Fax

Practice location:
  • Phone: 904-577-9908
  • Fax:
Mailing address:
  • Phone: 904-577-9908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCRPS.0101079.A
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: