Healthcare Provider Details

I. General information

NPI: 1235479130
Provider Name (Legal Business Name): JACKSONVILLE INJURY & REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 PARK AVE., SUITE # 102
ORANGE PARK FL
32073
US

IV. Provider business mailing address

859 PARK AVE STE 102
ORANGE PARK FL
32073-4151
US

V. Phone/Fax

Practice location:
  • Phone: 904-278-7411
  • Fax: 904-278-4446
Mailing address:
  • Phone: 904-278-7411
  • Fax: 904-278-4446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. REYNALDO PEREZ
Title or Position: MANAGING MEMBER
Credential: D.C.
Phone: 904-278-7411