1104121011 NPI number — FERNANDINA CHIROPRACTIC CENTER, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104121011 NPI number — FERNANDINA CHIROPRACTIC CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FERNANDINA CHIROPRACTIC CENTER, INC
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:
Provider Other Organization Name Type Code:
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:
1104121011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
464073 STATE ROAD 200
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
YULEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32097-6307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-491-1345
Provider Business Mailing Address Fax Number:
904-491-1346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
464073 STATE ROAD 200
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
YULEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32097-6307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-491-1345
Provider Business Practice Location Address Fax Number:
904-491-1346
Provider Enumeration Date:
01/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GLICKMAN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-491-1345

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH-3341 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016651900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com