Provider Demographics
NPI:1407420367
Name:FRAGOLA, BRENT VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:VINCENT
Last Name:FRAGOLA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 DANFORTH DR APT 1503
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-5231
Mailing Address - Country:US
Mailing Address - Phone:862-354-1780
Mailing Address - Fax:
Practice Address - Street 1:4413 TOWN CENTER PKWY STE 205
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8570
Practice Address - Country:US
Practice Address - Phone:904-221-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor