1982893509 NPI number — JUDO RYU JACKSONVILLE, INC

Table of content: (NPI 1982893509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982893509 NPI number — JUDO RYU JACKSONVILLE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUDO RYU 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:
1982893509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
691 SELVA LAKES CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTIC BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32233-7326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-349-0990
Provider Business Mailing Address Fax Number:
866-737-1635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1241 MAYPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTIC BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32233-3435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-349-0990
Provider Business Practice Location Address Fax Number:
866-737-1635
Provider Enumeration Date:
10/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANCHESTER
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING AGENT
Authorized Official Telephone Number:
904-777-5002

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT7180 , 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)

  • Identifier: Y4214 . This is a "BC/BS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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