Basic Information
| Provider Information | |||||||||
| NPI: | 1922511872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRETSCH | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 HIGHWAY 81 SOUTH | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300523918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705540665 | ||||||||
| FaxNumber: | 7705540685 | ||||||||
| Practice Location | |||||||||
| Address1: | 7939 HONEYGO BLVD STE 131 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212365905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109312738 | ||||||||
| FaxNumber: | 4109312739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2017 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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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 | 26776 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.