Healthcare Provider Details

I. General information

NPI: 1720668320
Provider Name (Legal Business Name): COLIN ECKERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

20 ROSEWOOD TRL
LONG VALLEY NJ
07853-3590
US

V. Phone/Fax

Practice location:
  • Phone: 727-898-7451
  • Fax:
Mailing address:
  • Phone: 973-787-7643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: