Provider Demographics
NPI:1427805571
Name:BARDROFF, DANE THOMAS
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:THOMAS
Last Name:BARDROFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3526 FORMOSA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2746 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7608
Practice Address - Country:US
Practice Address - Phone:970-832-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA103114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist