Healthcare Provider Details

I. General information

NPI: 1619267671
Provider Name (Legal Business Name): ANCIENT CITY CHILDREN'S THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 GIANNA WAY
ST AUGUSTINE FL
32086-3858
US

IV. Provider business mailing address

109 S. WINTERHAWK, SUITE 7
ST. AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-7886
  • Fax:
Mailing address:
  • Phone: 904-826-7886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12653
License Number StateFL

VIII. Authorized Official

Name: JOHANNIE GARCIA
Title or Position: OWNER
Credential: OTD
Phone: 904-826-7886