1164709812 NPI number — EAST COLONIAL CHIROPRACTIC OFFICE

Table of content: (NPI 1164709812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164709812 NPI number — EAST COLONIAL CHIROPRACTIC OFFICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST COLONIAL CHIROPRACTIC OFFICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JAFFE CHIROPRACTIC & WELLNESS CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164709812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11500 UNIVERSITY BLVD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32817-2197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-658-6500
Provider Business Mailing Address Fax Number:
407-277-2690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11500 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32817-2197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-658-6500
Provider Business Practice Location Address Fax Number:
407-277-2690
Provider Enumeration Date:
11/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOWLES
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
407-658-6500

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111NX0800X , with the licence number: CH0006110 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 051009200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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