Healthcare Provider Details

I. General information

NPI: 1134632474
Provider Name (Legal Business Name): NORTH FLORIDA SPORTS AND SPINE CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2758 US 1 S
SAINT AUGUSTINE FL
32086-6343
US

IV. Provider business mailing address

2758 US 1 S
SAINT AUGUSTINE FL
32086-6343
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-7765
  • Fax: 904-621-9202
Mailing address:
  • Phone: 904-429-7765
  • Fax: 904-621-9202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberME114798
License Number StateFL

VIII. Authorized Official

Name: DR. JOSHUA MICHAEL HENRY
Title or Position: OWNER
Credential: MD
Phone: 949-212-3425