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General NPI Number Information
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NPI Number | 1780944462
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Entity Type | Organization
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Legal Business Name | TANNER MARTINEZ CHIROPRACTIC LLC
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Dates
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Enumeration Date | 05/29/2012
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Last Update Date | 05/29/2012
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Provider Practice Location Address
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Address Line | 2200 N PONCE DE LEON BLVD SUITE 1
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-2600
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Country | US
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Telephone | 904-819-9110
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Fax | 904-819-9310
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Provider Business Mailing Address
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Address Line | 2200 N PONCE DE LEON BLVD SUITE 1
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-2600
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Country | US
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Telephone | 904-819-9110
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Fax | 904-819-9310
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. DUSTIN JAMES TANNER
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Credential |
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Telephone | 904-819-9110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NI0013X
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Taxonomy Name | Independent Medical Examiner Chiropractor
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License Number | CH10578
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH10578
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License Number State | FL
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