Provider Demographics
NPI:1780923623
Name:MISSO, CHRISTOPHER CHASE (LMT)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:CHASE
Last Name:MISSO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 BAYVIEW RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4215
Mailing Address - Country:US
Mailing Address - Phone:904-349-1188
Mailing Address - Fax:
Practice Address - Street 1:2200 N PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2600
Practice Address - Country:US
Practice Address - Phone:904-349-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43402225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist