1154750396 NPI number — DR. GEORGE PAUL HEBBLER III PT, DPT

Table of content: BRIAN JAMES WALSTROM PTA (NPI 1770029449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154750396 NPI number — DR. GEORGE PAUL HEBBLER III PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEBBLER
Provider First Name:
GEORGE
Provider Middle Name:
PAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
PT, DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1154750396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 MARINER HEALTH WAY STE 213
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32086-3251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-679-3449
Provider Business Mailing Address Fax Number:
904-679-3436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4320 A1A S STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32080-7436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-679-3449
Provider Business Practice Location Address Fax Number:
904-679-3436
Provider Enumeration Date:
11/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT28759 , 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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