Healthcare Provider Details

I. General information

NPI: 1730465451
Provider Name (Legal Business Name): JEFFERY KRECK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 DEFENDER COURT WEST
ATLANTIC BEACH FL
32233
US

IV. Provider business mailing address

1401 DEFENDER COURT WEST
ATLANTIC BEACH FL
32233
US

V. Phone/Fax

Practice location:
  • Phone: 609-501-0154
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number20709
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: