Provider Demographics
NPI:1083633200
Name:PAYNE CHIROPRACTIC LIFE CENTER PA
Entity Type:Organization
Organization Name:PAYNE CHIROPRACTIC LIFE CENTER PA
Other - Org Name:PAYNE CHIROPRACTIC WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-654-8770
Mailing Address - Street 1:4014 COMMONS DR W
Mailing Address - Street 2:UNIT 114
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8423
Mailing Address - Country:US
Mailing Address - Phone:850-654-8770
Mailing Address - Fax:850-654-1056
Practice Address - Street 1:4014 COMMONS DR W
Practice Address - Street 2:UNIT 114
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8423
Practice Address - Country:US
Practice Address - Phone:850-654-8770
Practice Address - Fax:850-654-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006929111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAK100Medicare PIN
FLU55579Medicare UPIN