Provider Demographics
NPI:1083039127
Name:CITY OF PALMS CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CITY OF PALMS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:NICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-615-7998
Mailing Address - Street 1:11621 S CLEVELAND AVE
Mailing Address - Street 2:UNIT 80
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-2866
Mailing Address - Country:US
Mailing Address - Phone:239-690-7794
Mailing Address - Fax:
Practice Address - Street 1:11621 S CLEVELAND AVE
Practice Address - Street 2:UNIT 80
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2866
Practice Address - Country:US
Practice Address - Phone:239-690-7794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-26
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10966111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty