Healthcare Provider Details

I. General information

NPI: 1679095954
Provider Name (Legal Business Name): DAVID JANTZ LAT, ATC, PES, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2017
Last Update Date: 07/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13895 HWY 27
LAKE WALES FL
33859-2549
US

IV. Provider business mailing address

13895 HIGHWAY 27
LAKE WALES FL
33859
US

V. Phone/Fax

Practice location:
  • Phone: 863-368-7567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAL3484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: