Healthcare Provider Details

I. General information

NPI: 1992141758
Provider Name (Legal Business Name): MR. CARL EUGENE BOX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 W WINDY WILLOW DR
ST AUGUSTINE FL
32092-5094
US

IV. Provider business mailing address

1509 W WINDY WILLOW DR
ST AUGUSTINE FL
32092-5094
US

V. Phone/Fax

Practice location:
  • Phone: 904-230-5400
  • Fax:
Mailing address:
  • Phone: 904-230-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: