Provider Demographics
NPI:1477384964
Name:GARVIN, IMMANUEL ISHMAEL (DC)
Entity type:Individual
Prefix:DR
First Name:IMMANUEL
Middle Name:ISHMAEL
Last Name:GARVIN
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:PO BOX 26092
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-6092
Mailing Address - Country:US
Mailing Address - Phone:904-803-1673
Mailing Address - Fax:
Practice Address - Street 1:2905 EGRET WALK TER S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-4474
Practice Address - Country:US
Practice Address - Phone:904-803-1673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15083111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor