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General NPI Number Information
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NPI Number | 1467068023
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Entity Type | Organization
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Legal Business Name | RIDE THE WAVE THERAPY SERVICES
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Dates
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Enumeration Date | 09/18/2020
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Last Update Date | 09/18/2020
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Provider Practice Location Address
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Address Line | 150 SOUTHPARK BLVD STE 202
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-5179
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Country | US
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Telephone | 904-217-3103
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Fax |
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Provider Business Mailing Address
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Address Line | 247 PORTADA DR
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32095-1637
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JANA SANFORD-HELLER
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Credential |
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Telephone | 352-256-0658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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