Healthcare Provider Details

I. General information

NPI: 1154462448
Provider Name (Legal Business Name): LORETTA N HURTAK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORI N HURTAK PT

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 SAN JOSE BLVD SUITE 210
JACKSONVILLE FL
32223-0756
US

IV. Provider business mailing address

11848 STONEBRIDGE DR W
JACKSONVILLE FL
32223-1886
US

V. Phone/Fax

Practice location:
  • Phone: 904-858-7450
  • Fax: 904-858-7451
Mailing address:
  • Phone: 904-880-1788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6320
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: