Healthcare Provider Details

I. General information

NPI: 1922378371
Provider Name (Legal Business Name): AUTUM BLAIR DENMARK P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 NW HALL OF FAME DR
LAKE CITY FL
32055-4833
US

IV. Provider business mailing address

404 NW HALL OF FAME DR
LAKE CITY FL
32055-4833
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3164
  • Fax: 386-755-3165
Mailing address:
  • Phone: 386-755-3164
  • Fax: 386-755-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA23022
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: