Healthcare Provider Details

I. General information

NPI: 1053547083
Provider Name (Legal Business Name): COMPREHENSIVE VASCULAR DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1892 BELLAIR BLVD
ORANGE PARK FL
32073-4548
US

IV. Provider business mailing address

1892 BELLAIR BLVD
ORANGE PARK FL
32073-4548
US

V. Phone/Fax

Practice location:
  • Phone: 904-541-0207
  • Fax: 904-264-2067
Mailing address:
  • Phone: 904-541-0207
  • Fax: 904-264-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRYAN K JACOBS
Title or Position: DIRECTOR
Credential:
Phone: 904-541-0207