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General NPI Number Information
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NPI Number | 1306556550
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Entity Type | Organization
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Legal Business Name | JACKSONVILLE SPINE CENTER PA
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Dates
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Enumeration Date | 11/29/2022
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Last Update Date | 11/29/2022
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Provider Practice Location Address
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Address Line | 2550 PARK ST STE B
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4518
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Country | US
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Telephone | 904-223-3321
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Fax | 904-223-2169
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Provider Business Mailing Address
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Address Line | 5191 FIRST COAST TECH PKWY FL 3
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City | JACKSONVILLE
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State | FL
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Zip | 32224-0609
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Country | US
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Telephone | 904-223-3321
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Fax | 904-223-2169
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Authorized Official
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Title or Position | CREDENTIALING
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Name | ALICIA M GROTH
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Credential |
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Telephone | 904-223-3321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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