Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology | PT36810 | FL |
NPI | 1649932799 |
---|---|
Provider Name | Connor Vice |
First Address | Jacksonville, FL 32216-4312 |
Second Address | Jacksonville, FL 32216-4312 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2021 |
Last Update Date | 06/10/2021 |