1508893579 NPI number — JACKSONVILLE IMPOTENCE TREATMENT CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508893579 NPI number — JACKSONVILLE IMPOTENCE TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSONVILLE IMPOTENCE TREATMENT CENTER
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:
JITC
Provider Other Organization Name Type Code:
3
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:
1508893579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2950 HALCYON LANE
Provider Second Line Business Mailing Address:
SUITE706
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-880-1366
Provider Business Mailing Address Fax Number:
904-880-8038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 HALCYON LANE
Provider Second Line Business Practice Location Address:
SUITE706
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-880-1366
Provider Business Practice Location Address Fax Number:
904-880-8038
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT., JITC
Authorized Official Telephone Number:
904-880-1366

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  ME0053960 , 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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