Basic Information
| Provider Information | |||||||||
| NPI: | 1275017972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 190 SOUTHPARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048241478 | ||||||||
| FaxNumber: | 9048248071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2018 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT4227 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT4227 | 01 | FL | OT LICENSE | OTHER |