Healthcare Provider Details

I. General information

NPI: 1285773036
Provider Name (Legal Business Name): LAURENCE LAYNE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CLARK ST
ST AUGUSTINE FL
32084-4158
US

IV. Provider business mailing address

PO BOX 4578
ST AUGUSTINE FL
32085-4578
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-1965
  • Fax: 904-826-1040
Mailing address:
  • Phone: 904-826-1965
  • Fax: 904-826-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA10746
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: