Provider Demographics
NPI:1982893509
Name:JUDO RYU JACKSONVILLE, INC
Entity Type:Organization
Organization Name:JUDO RYU JACKSONVILLE, INC
Other - Org Name:GENTLE WAY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-777-5002
Mailing Address - Street 1:691 SELVA LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-7326
Mailing Address - Country:US
Mailing Address - Phone:904-349-0990
Mailing Address - Fax:866-737-1635
Practice Address - Street 1:1241 MAYPORT RD
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-3435
Practice Address - Country:US
Practice Address - Phone:904-349-0990
Practice Address - Fax:866-737-1635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY4214OtherBC/BS OF FLORIDA
FL=========OtherTRICARE
FLQ14093Medicare UPIN
FL=========OtherTRICARE