Provider Demographics
NPI:1033302492
Name:VENICE VILLAGE CHIROPRACTIC CLINIC PA
Entity Type:Organization
Organization Name:VENICE VILLAGE CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-497-7424
Mailing Address - Street 1:4140 WOODMERE PARK BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-2205
Mailing Address - Country:US
Mailing Address - Phone:941-497-7424
Mailing Address - Fax:941-493-8413
Practice Address - Street 1:4140 WOODMERE PARK BLVD
Practice Address - Street 2:STE 2
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-2205
Practice Address - Country:US
Practice Address - Phone:941-497-7424
Practice Address - Fax:941-493-8413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7387111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38112550Medicaid
FL38112550Medicaid
FL55735Medicare PIN