Provider Demographics
NPI:1306960158
Name:PACE, SAMUEL DAVID (MSCD, LMT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DAVID
Last Name:PACE
Suffix:
Gender:M
Credentials:MSCD, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209-1 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4907
Mailing Address - Country:US
Mailing Address - Phone:904-737-9553
Mailing Address - Fax:
Practice Address - Street 1:4209-1 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4907
Practice Address - Country:US
Practice Address - Phone:904-737-9553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA20387174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM9926OtherMASSGE ESTABLISHMENT
FLMA30387OtherMASSAGE THEAPY LICENSE