Individual
MRS. TINA PATRICE BRISTOL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4455 ISH BRANT RD W, JACKSONVILLE, FL 32210-7046
(904) 377-6612
Mailing address
4455 ISH BRANT RD W, JACKSONVILLE, FL 32210-7046
(904) 377-6612
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
016780800
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
016780800
—
FL
05
—
B62381764947-0
—
FL
Enumeration date
02/04/2022
Last updated
02/04/2022
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