Provider Demographics
NPI:1750458378
Name:HARTLEY, J EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:EDWARD
Last Name:HARTLEY
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 1:1740 TREE BLVD
Mailing Address - Street 2:STE 115
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5720
Mailing Address - Country:US
Mailing Address - Phone:904-679-3233
Mailing Address - Fax:904-679-3599
Practice Address - Street 1:1740 TREE BLVD
Practice Address - Street 2:STE 115
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5720
Practice Address - Country:US
Practice Address - Phone:904-679-3233
Practice Address - Fax:904-679-3599
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6696111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380921800Medicaid
FL593375448OtherTAX ID
FL593375448OtherTAX ID
FLU40471Medicare UPIN