Healthcare Provider Details

I. General information

NPI: 1194248229
Provider Name (Legal Business Name): JACKSONVILLE SPINE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 09/26/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PLANTATION ISLAND DR S STE 220
ST AUGUSTINE FL
32080-5174
US

IV. Provider business mailing address

5191 FIRST COAST TECH PKWY 3RD FLOOR
JACKSONVILLE FL
32224
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-3321
  • Fax: 904-223-2169
Mailing address:
  • Phone: 904-223-3321
  • Fax: 904-223-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALICIA GROTH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 904-223-3321