Healthcare Provider Details

I. General information

NPI: 1780944462
Provider Name (Legal Business Name): TANNER MARTINEZ CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
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: 904-819-9110
  • Fax: 904-819-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberCH10578
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH10578
License Number StateFL

VIII. Authorized Official

Name: DR. DUSTIN JAMES TANNER
Title or Position: DOCTOR
Credential:
Phone: 904-819-9110