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Specialty details in registry · Jacksonville, FL

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At a glance

2647 Glory Trl, Jacksonville, FL 32210-3588

NPPES record updated May 19, 2026. Public records can lag behind changes at a practice.

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Practice location

2647 Glory Trl
Jacksonville, FL 32210-3588

Professional details: NPI, taxonomy & registry record

NPI1639009061

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Registry details

Primary taxonomy: Specialty details in registry
Taxonomy code: 171M00000X
Enumeration date: May 19, 2026
Record updated: May 19, 2026

More registry details

Provider type: Organization · Type 2

Reported taxonomies and licenses

Specialty details in registry

164W00000X

Specialty details in registry

171M00000X · Primary

License numbers and credentials are reported to NPPES; HCPList does not independently verify them.

Practice location

2647 Glory Trl
Jacksonville, FL 32210-3588

Phone: (929) 636-8373

Mailing address

2647 GLORY TRL

JACKSONVILLE, FL 322103588

Source: NPPES Source through Oct 18, 2026An NPI does not verify licensure or credentials.

Information may be outdated or incomplete. Confirm details directly with the practice. HCPList is an independent directory and is not affiliated with CMS.

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