1629258330 NPI number — MAURICIO CHIROPRACTIC GROUP INC

Table of content: (NPI 1629258330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629258330 NPI number — MAURICIO CHIROPRACTIC GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAURICIO CHIROPRACTIC GROUP 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:
1629258330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12278 E. COLONIAL DR.
Provider Second Line Business Mailing Address:
STE #600B
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-381-0878
Provider Business Mailing Address Fax Number:
407-373-6046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4747 S. CONWAY ROAD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-240-8430
Provider Business Practice Location Address Fax Number:
407-438-8905
Provider Enumeration Date:
11/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BIRD
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
407-381-0878

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH7735 , 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: 000681100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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