Healthcare Provider Details

I. General information

NPI: 1801341417
Provider Name (Legal Business Name): BETHANY GARRETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 PHOENETIA DR
ST AUGUSTINE FL
32086-7338
US

IV. Provider business mailing address

1409 ROYAL GROVE LN
PORT ORANGE FL
32129-8998
US

V. Phone/Fax

Practice location:
  • Phone: 386-341-4310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH11940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: