Provider Demographics
NPI:1083918023
Name:HEATHROW CHIROPRACTIC INC
Entity Type:Organization
Organization Name:HEATHROW CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-829-2133
Mailing Address - Street 1:120 INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 124
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5031
Mailing Address - Country:US
Mailing Address - Phone:407-829-2133
Mailing Address - Fax:407-829-2135
Practice Address - Street 1:120 INTERNATIONAL PKWY
Practice Address - Street 2:SUITE 124
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5031
Practice Address - Country:US
Practice Address - Phone:407-829-2133
Practice Address - Fax:407-829-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9620111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty