1619241890 NPI number — BEACH BOULEVARD CHIROPRACTIC

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 1619241890 NPI number — BEACH BOULEVARD CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACH BOULEVARD CHIROPRACTIC
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:
1619241890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11915 BEACH BLVD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32246-6704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-683-0793
Provider Business Mailing Address Fax Number:
904-619-4740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11915 BEACH BLVD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32246-6704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-683-0793
Provider Business Practice Location Address Fax Number:
904-619-4740
Provider Enumeration Date:
03/06/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WINKLER
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
DOCTOR / MANAGER
Authorized Official Telephone Number:
954-801-4465

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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