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General NPI Number Information
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NPI Number | 1275329823
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Entity Type | Organization
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Legal Business Name | JACKSONVILLE PEDIATRICS WORLD GOLF VILLAGE PLLC
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Dates
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Enumeration Date | 04/18/2025
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Last Update Date | 04/18/2025
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Provider Practice Location Address
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Address Line | 130 LAND GRANT STREET SUITE 3
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City | ST AUGUSTINE
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State | FL
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Zip | 32092
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Country | US
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Telephone | 904-388-4646
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Fax |
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Provider Business Mailing Address
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Address Line | 2606 PARK ST
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4520
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Country | US
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Telephone | 904-388-4646
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Fax | 904-388-9017
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Authorized Official
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Title or Position | PHYSICIAN
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Name | RYAN C CANTVILLE
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Credential | DO
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Telephone | 904-388-4646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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