1780006403 NPI number — PURE CHIROPRACTIC & NATURAL HEALTH, PA

Table of content: (NPI 1780006403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780006403 NPI number — PURE CHIROPRACTIC & NATURAL HEALTH, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURE CHIROPRACTIC & NATURAL HEALTH, PA
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:
1780006403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 WAYMONT CT
Provider Second Line Business Mailing Address:
SUITE 126, UNIT #3
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-3413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-682-4454
Provider Business Mailing Address Fax Number:
407-682-3805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 WAYMONT CT
Provider Second Line Business Practice Location Address:
SUITE 126, UNIT #3
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-3413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-682-4454
Provider Business Practice Location Address Fax Number:
407-682-3805
Provider Enumeration Date:
01/15/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WIEDER
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-682-4454

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH3063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111NI0013X , with the licence number: CH3063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133N00000X , with the licence number: CH3063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X , with the licence number: CH3063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1194299950 . This is a "STATE OF OHIO WORKER'S COMPENSATION" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CH3063 . This is a "STATE OF FLORIDA WORKER'S COMPENSATION" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 88322A . This is a "BLUE CROSSS & BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".