Provider Demographics
NPI:1811758667
Name:CALTRIDER, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:CALTRIDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13543 FLADGATE MARK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2381
Mailing Address - Country:US
Mailing Address - Phone:561-339-0446
Mailing Address - Fax:
Practice Address - Street 1:3935 UPPER CREEK DR
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6876
Practice Address - Country:US
Practice Address - Phone:561-339-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist