1679673396 NPI number — PALM COAST CHIROPRACTIC CENTER, JTA 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 1679673396 NPI number — PALM COAST CHIROPRACTIC CENTER, JTA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALM COAST CHIROPRACTIC CENTER, JTA 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:
1679673396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4721 E MOODY BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BUNNELL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32110-7706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-437-7111
Provider Business Mailing Address Fax Number:
386-437-7790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4721 E MOODY BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BUNNELL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32110-7706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-437-7111
Provider Business Practice Location Address Fax Number:
386-437-7790
Provider Enumeration Date:
09/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THORNTON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
386-437-7111

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH8483 , 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: 101964100 . 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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