1285062851 NPI number — PREMIER PHYSICAL THERAPY AND REHABILITATION OF JACKSONVILLE, INC

Table of content: CAROL JEAN GLENN MSW (NPI 1124278445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285062851 NPI number — PREMIER PHYSICAL THERAPY AND REHABILITATION OF JACKSONVILLE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PHYSICAL THERAPY AND REHABILITATION OF JACKSONVILLE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285062851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13947 BEACH BLVD STE 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32224-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-996-6922
Provider Business Mailing Address Fax Number:
904-996-6922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4320 PABLO PROFESSIONAL CT # 155
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32224-3219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-996-6922
Provider Business Practice Location Address Fax Number:
904-996-6922
Provider Enumeration Date:
10/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ARNOLD
Authorized Official First Name:
KRISTIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
904-996-6922

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  PTA23828 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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