Healthcare Provider Details

I. General information

NPI: 1649094335
Provider Name (Legal Business Name): IAN YETZKE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10629 BIG BEND RD STE 224
RIVERVIEW FL
33579-7176
US

IV. Provider business mailing address

4950 W PRESCOTT ST
TAMPA FL
33616-2903
US

V. Phone/Fax

Practice location:
  • Phone: 813-590-7799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number14545
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: