1689870412 NPI number — MAURICIO CHIROPRACTIC SOUTH L L C

Table of content: (NPI 1689870412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689870412 NPI number — MAURICIO CHIROPRACTIC SOUTH L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAURICIO CHIROPRACTIC SOUTH L L C
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:
1689870412
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 600C
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:
12720 S ORANGE BLOSSOM TRAIL
Provider Second Line Business Practice Location Address:
#20
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-438-4888
Provider Business Practice Location Address Fax Number:
321-319-0026
Provider Enumeration Date:
06/27/2007

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:
402-381-0878

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)

  • Identifier: 000681300 . 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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