Provider Demographics
NPI:1144567751
Name:ADVANCED CHIROPRACTIC LIFE CENTER, INC
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC LIFE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-338-5897
Mailing Address - Street 1:801 W GRANADA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8279
Mailing Address - Country:US
Mailing Address - Phone:386-673-2000
Mailing Address - Fax:386-673-2002
Practice Address - Street 1:801 W GRANADA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8279
Practice Address - Country:US
Practice Address - Phone:386-673-2000
Practice Address - Fax:386-673-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22973Medicare UPIN