Healthcare Provider Details

I. General information

NPI: 1871497107
Provider Name (Legal Business Name): ENDEVAWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 FOUNTAINS WAY STE 6
ST JOHNS FL
32259-1144
US

IV. Provider business mailing address

155 FOUNTAINS WAY STE 6
ST JOHNS FL
32259-1144
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-5455
  • Fax:
Mailing address:
  • Phone: 904-342-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT T. HARDMAN
Title or Position: OWNER/CEO
Credential: DC
Phone: 904-342-5455