Healthcare Provider Details

I. General information

NPI: 1346415627
Provider Name (Legal Business Name): ELDON RICHARD KILPATRICK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 JERRY BROWNE RD
MYSTIC CT
06355
US

IV. Provider business mailing address

333 1ST STREET NORTH SUITE 200
JACKSONVILLE BEACH FL
32250
US

V. Phone/Fax

Practice location:
  • Phone: 866-338-8892
  • Fax:
Mailing address:
  • Phone: 904-241-9231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number000980
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: