Healthcare Provider Details

I. General information

NPI: 1790012201
Provider Name (Legal Business Name): DUSTIN JAMES TANNER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N PONCE DE LEON BLVD SUITE #1
ST AUGUSTINE FL
32084-2600
US

IV. Provider business mailing address

2200 N PONCE DE LEON BLVD SUITE #1
ST AUGUSTINE FL
32084-2600
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-9110
  • Fax: 904-819-9310
Mailing address:
  • Phone: 315-224-4042
  • Fax: 904-819-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH 10578
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX012022-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: