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General NPI Number Information
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NPI Number | 1568940617
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Entity Type | Individual
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Provider Name | KEVIN SHADDOCK DPT
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Gender | Male
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Dates
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Enumeration Date | 07/31/2018
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Last Update Date | 07/31/2018
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Provider Practice Location Address
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Address Line | 816 A1A N STE 307
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City | PONTE VEDRA
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State | FL
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Zip | 32082-3219
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Country | US
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Telephone | 402-190-4543
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Fax |
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Provider Business Mailing Address
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Address Line | 3901 UNIVERSITY BLVD S
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City | JACKSONVILLE
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State | FL
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Zip | 32216-4312
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Country | US
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Telephone | 904-345-7336
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251G0304X
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Taxonomy Name | Geriatric Physical Therapist
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License Number | PT33637
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License Number State | FL
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