=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407420367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENT VINCENT FRAGOLA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2021
-----------------------------------------------------
Last Update Date | 05/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4413 TOWN CENTER PKWY STE 205
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-8570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-221-7799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3701 DANFORTH DR APT 1503
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-5231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-354-1780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 13292
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------