Provider Demographics
NPI:1114143278
Name:HERON LAKES CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:HERON LAKES CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:STEPHAN
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-341-2256
Mailing Address - Street 1:5675 CORAL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3124
Mailing Address - Country:US
Mailing Address - Phone:954-341-2256
Mailing Address - Fax:954-341-2264
Practice Address - Street 1:5675 CORAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-3124
Practice Address - Country:US
Practice Address - Phone:954-341-2256
Practice Address - Fax:954-341-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8680111N00000X
FLCH8773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty