Provider Demographics
NPI:1760722011
Name:PHYSICAL HEALTHCARE OF JACKSONVILLE INC
Entity Type:Organization
Organization Name:PHYSICAL HEALTHCARE OF JACKSONVILLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-645-0777
Mailing Address - Street 1:12620 BEACH BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7131
Mailing Address - Country:US
Mailing Address - Phone:904-645-0777
Mailing Address - Fax:904-645-3483
Practice Address - Street 1:12620 BEACH BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7131
Practice Address - Country:US
Practice Address - Phone:904-645-0777
Practice Address - Fax:904-645-3483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6451111N00000X
FLCH6588111N00000X
FLCH4435111N00000X
FLME55161207R00000X, 332B00000X
FLME0060908208100000X, 332B00000X
FLPT30658225100000X
FLPA9106788363AM0700X
FLARNP 770742363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6736700001Medicare NSC
FLHF195AMedicare UPIN