Healthcare Provider Details

I. General information

NPI: 1780923623
Provider Name (Legal Business Name): CHRISTOPHER CHASE MISSO LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N PONCE DE LEON BLVD
ST AUGUSTINE FL
32084-2600
US

IV. Provider business mailing address

2310 BAYVIEW RD
JACKSONVILLE FL
32210-4215
US

V. Phone/Fax

Practice location:
  • Phone: 904-349-1188
  • Fax:
Mailing address:
  • Phone: 904-349-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA43402
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: