Provider Demographics
NPI:1679095954
Name:JANTZ, DAVID (LAT, ATC, PES, CES)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JANTZ
Suffix:
Gender:M
Credentials:LAT, ATC, PES, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13895 HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13895 HWY 27
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-2549
Practice Address - Country:US
Practice Address - Phone:863-368-7567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-08
Last Update Date:2017-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL34842081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty