1861069676 NPI number — PROGRESSIVE PEDIATRIC THERAPY SERVICES OF JACKSONVILLE

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 1861069676 NPI number — PROGRESSIVE PEDIATRIC THERAPY SERVICES OF JACKSONVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE PEDIATRIC THERAPY SERVICES OF JACKSONVILLE
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:
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:
1861069676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1725 HERMITAGE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-7709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-325-6301
Provider Business Mailing Address Fax Number:
850-352-6302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12350 SHORE ACRES DR
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:
32225-5670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-325-6301
Provider Business Practice Location Address Fax Number:
850-325-6302
Provider Enumeration Date:
06/09/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PREJEAN
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
QUIN
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
850-325-6301

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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