Healthcare Provider Details

I. General information

NPI: 1649826900
Provider Name (Legal Business Name): JACKSONVILLE ORTHOPAEDIC INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MURABELLA PKWY STE 6
ST AUGUSTINE FL
32092-4540
US

IV. Provider business mailing address

PO BOX 117345
ATLANTA GA
30368-7345
US

V. Phone/Fax

Practice location:
  • Phone: 904-224-2666
  • Fax: 904-224-2667
Mailing address:
  • Phone: 904-346-3465
  • Fax: 904-858-6489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY WALL
Title or Position: ADMINISTRATOR
Credential:
Phone: 904-858-7045