Basic Information
| Provider Information | |||||||||
| NPI: | 1093906869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDENBURG | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77079 COBBLESTONE DR | ||||||||
| Address2: | |||||||||
| City: | YULEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320970645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305912820 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2080 CHILD ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322143328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045427375 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 27117 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.