Basic Information
| Provider Information | |||||||||
| NPI: | 1104055045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRETCKO | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6169 JOG RD | ||||||||
| Address2: | SUITE A11 | ||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334676579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Practice Location | |||||||||
| Address1: | 3925 SHERIDAN DR | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142261738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162506492 | ||||||||
| FaxNumber: | 7162504178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 043062 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT-26998 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.