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General NPI Number Information
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NPI Number | 1912691536
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Entity Type | Individual
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Provider Name | JUSTIN VAN DUYNE LMT
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Gender | Male
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Dates
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Enumeration Date | 06/06/2023
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Last Update Date | 06/06/2023
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Provider Practice Location Address
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Address Line | 1310 N 2ND ST APT 2412
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City | PHOENIX
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State | AZ
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Zip | 85004-1778
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Country | US
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Telephone | 929-303-4423
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Fax |
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Provider Business Mailing Address
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Address Line | 623 EAGLE ROCK AVE # 199
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City | WEST ORANGE
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State | NJ
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Zip | 07052-2948
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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 |
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Name |
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Credential |
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Telephone |
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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 | MT-29051
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License Number State | AZ
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