Provider Demographics
NPI:1225469430
Name:JAYNE KWIATKOWSKI LLC
Entity Type:Organization
Organization Name:JAYNE KWIATKOWSKI LLC
Other - Org Name:TOMOKA SPINE AND POSTURE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KWIATKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-872-5323
Mailing Address - Street 1:208 BOOTH RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5717
Mailing Address - Country:US
Mailing Address - Phone:386-872-5323
Mailing Address - Fax:
Practice Address - Street 1:208 BOOTH RD
Practice Address - Street 2:SUITE 1
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5717
Practice Address - Country:US
Practice Address - Phone:386-872-5323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9417261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL382271100Medicaid