1023493079 NPI number — DR. SHAUN JANSE VAN RENSBURG D.C.

Table of content: DR. SHAUN JANSE VAN RENSBURG D.C. (NPI 1023493079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023493079 NPI number — DR. SHAUN JANSE VAN RENSBURG D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANSE VAN RENSBURG
Provider First Name:
SHAUN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023493079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6500 BOWDEN RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-8070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-634-0640
Provider Business Mailing Address Fax Number:
904-634-0203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2627 RIVERSIDE AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-4712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-634-0640
Provider Business Practice Location Address Fax Number:
904-634-0203
Provider Enumeration Date:
07/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH11443 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108060500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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