=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861089062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSONVILLE INTEGRATIVE HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2020
-----------------------------------------------------
Last Update Date | 09/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13241 BARTRAM PARK BLVD UNIT 2501
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-299-6000
-----------------------------------------------------
Fax | 904-299-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13241 BARTRAM PARK BLVD UNIT 2501
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-621-4222
-----------------------------------------------------
Fax | 904-299-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GABRIEL BUSQUETS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-621-4222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------