Provider Demographics
NPI:1194857359
Name:DAYTONA CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:DAYTONA CHIROPRACTIC CLINIC LLC
Other - Org Name:HILL MATT DR SOLE MBR
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-253-1113
Mailing Address - Street 1:543 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4929
Mailing Address - Country:US
Mailing Address - Phone:386-253-1113
Mailing Address - Fax:
Practice Address - Street 1:543 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4929
Practice Address - Country:US
Practice Address - Phone:386-253-1113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6956Medicare ID - Type Unspecified