Provider Demographics
NPI:1124567730
Name:CHIROPRACTIC & GENETIC WELLNESS, LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC & GENETIC WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RUTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-212-8700
Mailing Address - Street 1:7035 BERACASA WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3405
Mailing Address - Country:US
Mailing Address - Phone:610-212-8700
Mailing Address - Fax:561-447-4556
Practice Address - Street 1:1401 S OCEAN BLVD
Practice Address - Street 2:#302
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-8528
Practice Address - Country:US
Practice Address - Phone:610-212-8700
Practice Address - Fax:561-447-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA194396RT2Medicare UPIN