Healthcare Provider Details

I. General information

NPI: 1649053406
Provider Name (Legal Business Name): JOHN FITZGERALD KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 TURKEY LAKE RD STE 114
ORLANDO FL
32819-4205
US

IV. Provider business mailing address

6000 TURKEY LAKE RD STE 114
ORLANDO FL
32819-4205
US

V. Phone/Fax

Practice location:
  • Phone: 321-732-3723
  • Fax: 321-352-7168
Mailing address:
  • Phone: 321-732-3723
  • Fax: 321-352-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-291204
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: