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General NPI Number Information
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NPI Number | 1609279405
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Entity Type | Organization
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Legal Business Name | ERGO BODY INC.
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Dates
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Enumeration Date | 10/07/2014
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Last Update Date | 10/07/2014
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Provider Practice Location Address
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Address Line | 1555 SAN MARCO BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32207-2905
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Country | US
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Telephone | 904-536-1829
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Fax | 904-396-1787
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Provider Business Mailing Address
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Address Line | 3655 SAN JOSE BLVD.
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City | JACKSONVILLE
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State | FL
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Zip | 32207-5224
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Country | US
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Telephone | 904-536-1829
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Fax | 904-396-1787
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Authorized Official
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Title or Position | PRESIDENT, PHYSICAL THERAPIST
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Name | ILENE M CHAZAN
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Credential | PT
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Telephone | 904-536-1829
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 19701
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License Number State | FL
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