Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH 8960 | FL |
NPI | 1447317391 |
---|---|
Provider Name | Dr. Jon Michael Repole |
First Address | Jacksonville, FL 32259-5410 |
Second Address | Jacksonville, FL 32223-6671 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2007 |
Last Update Date | 05/05/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U88156 | (02) |