Healthcare Provider Details

I. General information

NPI: 1295544203
Provider Name (Legal Business Name): ERIC JOSEPH MAGNIFICO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 LAND GRANT ST SAUITE 4
SAINT AUGUSTINE FL
32092
US

IV. Provider business mailing address

145 LAND GRANT ST SAUITE 4
SAINT AUGUSTINE FL
32092
US

V. Phone/Fax

Practice location:
  • Phone: 904-250-0205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number15294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: