Provider Demographics
NPI:1790149516
Name:KICK SOME MASS LLC
Entity Type:Organization
Organization Name:KICK SOME MASS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALLYN
Authorized Official - Last Name:RUTERBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-589-0750
Mailing Address - Street 1:316 PARKRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7507
Mailing Address - Country:US
Mailing Address - Phone:904-589-0750
Mailing Address - Fax:904-375-8821
Practice Address - Street 1:316 PARKRIDGE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7507
Practice Address - Country:US
Practice Address - Phone:904-589-0750
Practice Address - Fax:904-375-8821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
FLOS64032081S0010X, 2083P0901X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIP327AOtherPTAN