1912171943 NPI number — ST CLOUD CHIROPRACTIC, INC

Table of content: (NPI 1912171943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912171943 NPI number — ST CLOUD CHIROPRACTIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST CLOUD CHIROPRACTIC, 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:
1912171943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 701757
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34770-1757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-892-5008
Provider Business Mailing Address Fax Number:
407-892-5028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1106 10TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34769-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-892-5008
Provider Business Practice Location Address Fax Number:
407-892-5028
Provider Enumeration Date:
04/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CULLINANE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-892-5008

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH6290 , 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: 22605 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 052561800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".