=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639652704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN M HOSEK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2018
-----------------------------------------------------
Last Update Date | 09/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 NATIONAL HEALTH CARE DR
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-1494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-257-6362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 FOX RUN TRL
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-4911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA28822
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------