Healthcare Provider Details

I. General information

NPI: 1841673928
Provider Name (Legal Business Name): KICK SOME MASS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 PARKRIDGE AVE
ORANGE PARK FL
32065-7507
US

IV. Provider business mailing address

316 PARKRIDGE AVE
ORANGE PARK FL
32065-7507
US

V. Phone/Fax

Practice location:
  • Phone: 904-589-0750
  • Fax:
Mailing address:
  • Phone: 904-589-0750
  • Fax: 904-621-9300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY ALLYN RUTERBUSCH
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 904-505-0628