Provider Demographics
NPI:1053676502
Name:EXPRESS LIFE FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:EXPRESS LIFE FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-769-1585
Mailing Address - Street 1:450 NE 5TH ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3468
Mailing Address - Country:US
Mailing Address - Phone:954-769-1585
Mailing Address - Fax:888-332-1945
Practice Address - Street 1:450 NE 5TH ST
Practice Address - Street 2:SUITE 7
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3468
Practice Address - Country:US
Practice Address - Phone:954-769-1585
Practice Address - Fax:888-332-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7850111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty