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General NPI Number Information
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NPI Number | 1184130916
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Entity Type | Individual
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Provider Name | MANUEL GERVASIO RUIZ DICKS JR.
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Gender | Male
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Dates
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Enumeration Date | 12/15/2017
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Last Update Date | 09/29/2023
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Provider Practice Location Address
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Address Line | 6428 BEACH BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32216-2813
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Country | US
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Telephone | 904-475-2039
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Fax | 904-330-0668
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Provider Business Mailing Address
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Address Line | 6428 BEACH BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32216-2813
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Country | US
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Telephone | 904-475-2039
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Fax | 904-330-0668
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3226112
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License Number State | FL
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