Healthcare Provider Details

I. General information

NPI: 1174810956
Provider Name (Legal Business Name): BETHANN PATRICIA VETTER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 ISABELLA BLVD SUITE 50
JACKSONVILLE BEACH FL
32250-8005
US

IV. Provider business mailing address

2902 ISABELLA BLVD SUITE 50
JACKSONVILLE BEACH FL
32250-8005
US

V. Phone/Fax

Practice location:
  • Phone: 904-707-5029
  • Fax: 904-241-7132
Mailing address:
  • Phone: 904-707-5029
  • Fax: 904-241-7132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA22362
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: