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NPI Code Detail

MEDICARE: MR. BRIAN WILLIAM JANSEN ATC, LAT

MEDICARE: MR. BRIAN WILLIAM JANSEN ATC, LAT
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
1174400000XSpecialistAL 571FL

General Provider Information

NPI Number : 1922074293
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRIAN WILLIAM JANSEN ATC, LAT
Provider Business Mailing Address
First Line : 1610 3RD ST
Second Line :
City : DAYTONA BEACH
State : FL
Zip : 32117-4556
Country : US
Telephone Number : 386-341-3666
Fax Number :
Provider Business Practice Location Address
First Line : 640 DR MARY MCLEOD BETHUNE BLVD
Second Line :
City : DAYTONA BEACH
State : FL
Zip : 32114-3012
Country : US
Telephone Number : 386-481-2261
Fax Number : 386-481-2265
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/27/2006
Last Update Date : 07/08/2007

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