MEDICARE: JANET MOULTON, INC.

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1225654908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JANET MOULTON, INC.

Provider Business Mailing Address
First Line	:	340 16TH AVE N STE B
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4819
Country	:	US
Telephone Number	:	904-249-8893
Fax Number	:	904-372-0496

Provider Business Practice Location Address
First Line	:	463380 STATE ROAD 200 UNIT A
Second Line	:
City	:	YULEE
State	:	FL
Zip	:	32097-3240
Country	:	US
Telephone Number	:	904-249-8893
Fax Number	:	904-372-0496

Authorized Official
Title or Position	:	BILLING AGENT
Name	:	CHARLOTTE LAVERGNE
Credential	:
Telephone Number	:	904-879-4230

Provider Enumeration Date	:	06/18/2020
Last Update Date	:	06/18/2020

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