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General NPI Number Information
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NPI Number | 1235239625
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Entity Type | Organization
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Legal Business Name | JAD THERAPY LLC
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1669 SE HIGHWAY 19
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429
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Country | US
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Telephone | 352-563-2407
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Fax | 352-563-2807
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Provider Business Mailing Address
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Address Line | P.O. BOX 2154
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City | CRYSTAL RIVER
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State | FL
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Zip | 34423
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Country | US
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Telephone | 352-563-2407
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Fax | 352-563-2807
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Authorized Official
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Title or Position | CEO
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Name | JAMES ARTHUR DERRENBACKER JR.
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Credential | D.O.
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Telephone | 352-563-2407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | OS 0006090
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License Number State | FL
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