Provider Demographics
NPI:1104191428
Name:CHIROPRACTIC SPECIALIST OF BREVARD, INC.
Entity Type:Organization
Organization Name:CHIROPRACTIC SPECIALIST OF BREVARD, INC.
Other - Org Name:SUNTREE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-622-6778
Mailing Address - Street 1:1368 SILVER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1952
Mailing Address - Country:US
Mailing Address - Phone:321-622-6778
Mailing Address - Fax:
Practice Address - Street 1:130 INTERLACHEN RD
Practice Address - Street 2:SUITE D
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1994
Practice Address - Country:US
Practice Address - Phone:321-622-6778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty