Provider Demographics
NPI:1225654908
Name:JANET MOULTON, INC.
Entity Type:Organization
Organization Name:JANET MOULTON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVERGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-879-4230
Mailing Address - Street 1:340 16TH AVE N STE B
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4819
Mailing Address - Country:US
Mailing Address - Phone:904-249-8893
Mailing Address - Fax:904-372-0496
Practice Address - Street 1:463380 STATE ROAD 200 UNIT A
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3240
Practice Address - Country:US
Practice Address - Phone:904-249-8893
Practice Address - Fax:904-372-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy