=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255103875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK CACCESE AP, MAOM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2023
-----------------------------------------------------
Last Update Date | 10/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8855 SAN JOSE BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32217-4244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-260-2598
-----------------------------------------------------
Fax | 904-260-2599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8855 SAN JOSE BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32217-4244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-260-2598
-----------------------------------------------------
Fax | 904-260-2599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP4527
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------