Provider Demographics
NPI:1548547367
Name:MUCK, KENNETH EDWIN (LMT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EDWIN
Last Name:MUCK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1987 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3963
Mailing Address - Country:US
Mailing Address - Phone:321-626-9055
Mailing Address - Fax:888-372-9707
Practice Address - Street 1:1490 AVOCADO AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6532
Practice Address - Country:US
Practice Address - Phone:321-252-5253
Practice Address - Fax:888-372-9707
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29049225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist