Provider Demographics
NPI:1346961141
Name:RIECK, JEFFRY PAUL (RD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:PAUL
Last Name:RIECK
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-2773
Mailing Address - Country:US
Mailing Address - Phone:719-203-8052
Mailing Address - Fax:
Practice Address - Street 1:13800 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7401
Practice Address - Country:US
Practice Address - Phone:407-631-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered