Provider Demographics
NPI:1437337060
Name:CONDINO, CHARLY MAR
Entity Type:Individual
Prefix:
First Name:CHARLY MAR
Middle Name:
Last Name:CONDINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E FORSYTH ST APT 805
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-3344
Mailing Address - Country:US
Mailing Address - Phone:904-553-6199
Mailing Address - Fax:
Practice Address - Street 1:11565 HARTS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3777
Practice Address - Country:US
Practice Address - Phone:904-751-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist