Healthcare Provider Details

I. General information

NPI: 1164528915
Provider Name (Legal Business Name): PECKS FAMILY PRACTICE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1688 W GRANADA BLVD STE 2A
ORMOND BEACH FL
32174-1851
US

IV. Provider business mailing address

1688 W GRANADA BLVD STE 2A
ORMOND BEACH FL
32174-1851
US

V. Phone/Fax

Practice location:
  • Phone: 386-677-2018
  • Fax: 386-676-0737
Mailing address:
  • Phone: 386-677-2018
  • Fax: 386-676-0737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME71672
License Number StateFL

VIII. Authorized Official

Name: BENJAMIN JAY PECK
Title or Position: OWNER
Credential: MD
Phone: 386-677-2018