Healthcare Provider Details

I. General information

NPI: 1235435652
Provider Name (Legal Business Name): TRENT CHARLES HARRISON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 EAGLE HARBOR PARKWAY STE B
ORANGE PARK FL
32003
US

IV. Provider business mailing address

3599 UNIVERSITY BLVD SOUTH
JACKSONVILLE FL
32216
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0148
  • Fax:
Mailing address:
  • Phone: 904-858-7327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 26186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: