Healthcare Provider Details

I. General information

NPI: 1083779557
Provider Name (Legal Business Name): EDWARD TANZA JR. DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 TUSCAN WAY STE. 202-148
SAINT AUGUSTINE FL
32092-1850
US

IV. Provider business mailing address

52 TUSCAN WAY STE. 202-148
SAINT AUGUSTINE FL
32092-1850
US

V. Phone/Fax

Practice location:
  • Phone: 904-290-1846
  • Fax: 904-417-7177
Mailing address:
  • Phone: 904-290-1846
  • Fax: 904-417-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: