Provider Demographics
NPI:1083962526
Name:REGATTA CHIROPRACTIC AND LASER CENTER INC
Entity Type:Organization
Organization Name:REGATTA CHIROPRACTIC AND LASER CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-748-6102
Mailing Address - Street 1:5953 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-2320
Mailing Address - Country:US
Mailing Address - Phone:850-424-7856
Mailing Address - Fax:
Practice Address - Street 1:4481 LEGENDARY DR
Practice Address - Street 2:SUITE 150
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5381
Practice Address - Country:US
Practice Address - Phone:850-424-7856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2631473OtherUNITED HEALTHCARE