1679698336 NPI number — MR. JACK R RUST PHYSICAL THERAPIST

Table of content: MR. JACK R RUST PHYSICAL THERAPIST (NPI 1679698336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679698336 NPI number — MR. JACK R RUST PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUST
Provider First Name:
JACK
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679698336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 NE 45 ST
Provider Second Line Business Mailing Address:
#3
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-938-0154
Provider Business Mailing Address Fax Number:
954-492-1151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 NE 45 ST
Provider Second Line Business Practice Location Address:
#3
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-938-0154
Provider Business Practice Location Address Fax Number:
954-492-1151
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT0000326 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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