Healthcare Provider Details

I. General information

NPI: 1487732905
Provider Name (Legal Business Name): JEFFERY LEROUX ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 KINGSLEY AVE
ORANGE PARK FL
32073-4847
US

IV. Provider business mailing address

12793 86TH TER
LIVE OAK FL
32060-8829
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-2156
  • Fax:
Mailing address:
  • Phone: 386-364-1381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: