Provider Demographics
NPI:1114401544
Name:CHIRO & LASER PAIN RELIEF CENTER OF ST AUGUSTINE LLC
Entity Type:Organization
Organization Name:CHIRO & LASER PAIN RELIEF CENTER OF ST AUGUSTINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUPO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-460-2923
Mailing Address - Street 1:1092 S PONCE DE LEON BLVD STE K
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6018
Mailing Address - Country:US
Mailing Address - Phone:904-460-2923
Mailing Address - Fax:
Practice Address - Street 1:1092 S PONCE DE LEON BLVD STE K
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6018
Practice Address - Country:US
Practice Address - Phone:904-460-2923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty