MEDICARE: RICHARD MYERSTON PTA

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	PTA30574	FL

General Provider Information

NPI Number	:	1902413644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD MYERSTON PTA

Provider Business Mailing Address
First Line	:	6650 CORPORATE CENTER PKWY APT 717
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8730
Country	:	US
Telephone Number	:	904-423-7708
Fax Number	:

Provider Business Practice Location Address
First Line	:	6650 CORPORATE CENTER PKWY APT 717
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8730
Country	:	US
Telephone Number	:	904-423-7708
Fax Number	:

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

Provider Enumeration Date	:	09/27/2020
Last Update Date	:	09/27/2020

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