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General NPI Number Information
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NPI Number | 1659074276
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Entity Type | Organization
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Legal Business Name | BANDB1 LLC
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Dates
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Enumeration Date | 03/23/2023
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Last Update Date | 03/23/2023
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Provider Practice Location Address
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Address Line | 4870 BIG ISLAND DR STE 10
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City | JACKSONVILLE
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State | FL
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Zip | 32246-5300
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Country | US
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Telephone | 773-501-9110
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Fax |
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Provider Business Mailing Address
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Address Line | 24492 HARBOUR VIEW DR
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City | PONTE VEDRA
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State | FL
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Zip | 32082-2150
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Country | US
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Telephone | 773-501-9110
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL BROMILEY
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Credential |
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Telephone | 773-501-9110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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