Healthcare Provider Details

I. General information

NPI: 1881350676
Provider Name (Legal Business Name): JOHN PAUL CICCIARO JR. PT, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ORTHOPAEDIC PL
ST AUGUSTINE FL
32086-4202
US

IV. Provider business mailing address

7005 BERRYBROOK DR
JACKSONVILLE FL
32258-5533
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-0540
  • Fax:
Mailing address:
  • Phone: 304-972-5472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT38026
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: