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General NPI Number Information
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NPI Number | 1164528915
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Entity Type | Organization
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Legal Business Name | PECKS FAMILY PRACTICE PLC
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 08/12/2010
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Provider Practice Location Address
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Address Line | 1688 W GRANADA BLVD STE 2A
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City | ORMOND BEACH
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State | FL
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Zip | 32174-1851
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Country | US
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Telephone | 386-677-2018
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Fax | 386-676-0737
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Provider Business Mailing Address
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Address Line | 1688 W GRANADA BLVD STE 2A
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City | ORMOND BEACH
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State | FL
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Zip | 32174-1851
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Country | US
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Telephone | 386-677-2018
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Fax | 386-676-0737
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Authorized Official
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Title or Position | OWNER
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Name | BENJAMIN JAY PECK
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Credential | MD
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Telephone | 386-677-2018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME71672
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License Number State | FL
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