Basic Information
| Provider Information | |||||||||
| NPI: | 1376632760 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CANN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 NEW BOLTON DR | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321295315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303071118 | ||||||||
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| Practice Location | |||||||||
| Address1: | 540 KINGSLEY AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042642156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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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 | 225100000X | PT22621 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 891461300 | 05 | FL | MEDICAID |