Provider Demographics
NPI:1710779293
Name:CHILDERS, JUSTIN T
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:CHILDERS
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 1:777 GLADES RD # BC-71
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6496
Mailing Address - Country:US
Mailing Address - Phone:407-353-2467
Mailing Address - Fax:
Practice Address - Street 1:777 GLADES RD # BC-71
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6496
Practice Address - Country:US
Practice Address - Phone:407-353-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program