MEDICARE: MR. JOHN LAZARUS HARRIS JR. MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT19787	FL
2	225100000X	Physical Therapist	PT007271	GA

General Provider Information

NPI Number	:	1134113665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN LAZARUS HARRIS JR. MSPT

Provider Business Mailing Address
First Line	:	11953 BLUE SPRUCE CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-2924
Country	:	US
Telephone Number	:	904-880-2954
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 N RIDGECREST LN
Second Line	:	SUITE 100
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-3862
Country	:	US
Telephone Number	:	904-230-1232
Fax Number	:	904-230-1399

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	07/08/2007

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