Healthcare Provider Details

I. General information

NPI: 1194239459
Provider Name (Legal Business Name): PAUL KUDLICK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2017
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2864 WELLNESS AVE STE 100
ORANGE CITY FL
32763-8335
US

IV. Provider business mailing address

2864 WELLNESS AVE STE 100
ORANGE CITY FL
32763-8335
US

V. Phone/Fax

Practice location:
  • Phone: 386-575-4027
  • Fax: 386-575-4028
Mailing address:
  • Phone: 386-575-4027
  • Fax: 386-575-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT33066
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: