Provider Demographics
NPI:1619267671
Name:ANCIENT CITY CHILDREN'S THERAPY, LLC
Entity Type:Organization
Organization Name:ANCIENT CITY CHILDREN'S THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:OTD
Authorized Official - Phone:904-826-7886
Mailing Address - Street 1:109 S. WINTERHAWK,
Mailing Address - Street 2:SUITE 7
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-826-7886
Mailing Address - Fax:
Practice Address - Street 1:367 GIANNA WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3858
Practice Address - Country:US
Practice Address - Phone:904-826-7886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12653174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty