MEDICARE: DR. JAMES MITCHELL LANE PT, DPT

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	35898	FL

General Provider Information

NPI Number	:	1316545346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES MITCHELL LANE PT, DPT

Provider Business Mailing Address
First Line	:	3901 UNIVERSITY BLVD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4312
Country	:	US
Telephone Number	:	904-345-7251
Fax Number	:

Provider Business Practice Location Address
First Line	:	4701 CITY CENTER PKWY
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-4153
Country	:	US
Telephone Number	:	386-236-7010
Fax Number	:

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

Provider Enumeration Date	:	10/12/2020
Last Update Date	:	10/12/2020

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