Provider Demographics
NPI:1073799870
Name:PONTE VEDRA CHIROPRACTIC MEDICINE & PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PONTE VEDRA CHIROPRACTIC MEDICINE & PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:PACKO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-285-2243
Mailing Address - Street 1:240 PONTE VEDRA PARK DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6601
Mailing Address - Country:US
Mailing Address - Phone:904-285-2243
Mailing Address - Fax:904-285-9022
Practice Address - Street 1:240 PONTE VEDRA PARK DR
Practice Address - Street 2:SUITE 150
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6601
Practice Address - Country:US
Practice Address - Phone:904-285-2243
Practice Address - Fax:904-285-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6259111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty