MEDICARE: GLORYIAN D. EWING LMT, LPN

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	164W00000X	Licensed Practical Nurse	PN 5178499	FL
2	225700000X	Massage Therapist	MA44439	FL
3	225700000X	Massage Therapist	MA102448	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811215858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORYIAN D. EWING LMT, LPN

Provider Business Mailing Address
First Line	:	8407 HERLONG RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2327
Country	:	US
Telephone Number	:	904-666-8952
Fax Number	:

Provider Business Practice Location Address
First Line	:	6501 ARLINGTON EXPY BLDG A
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-5779
Country	:	US
Telephone Number	:	904-649-6084
Fax Number	:

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

Provider Enumeration Date	:	05/14/2010
Last Update Date	:	05/23/2023

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