Provider Demographics
NPI:1275329823
Name:JACKSONVILLE PEDIATRICS WORLD GOLF VILLAGE PLLC
Entity type:Organization
Organization Name:JACKSONVILLE PEDIATRICS WORLD GOLF VILLAGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CANTVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-388-4646
Mailing Address - Street 1:2606 PARK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4520
Mailing Address - Country:US
Mailing Address - Phone:904-388-4646
Mailing Address - Fax:904-388-9017
Practice Address - Street 1:130 LAND GRANT STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:904-388-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care