Provider Demographics
NPI:1336230796
Name:FRISVOLD, JOHN MILES (DPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MILES
Last Name:FRISVOLD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E FOREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6605
Mailing Address - Country:US
Mailing Address - Phone:386-937-5073
Mailing Address - Fax:
Practice Address - Street 1:3715 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-9168
Practice Address - Country:US
Practice Address - Phone:386-329-2613
Practice Address - Fax:386-329-2614
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY115ROtherBCBS
FLY115ROtherBCBS