Provider Demographics
NPI:1235481524
Name:1 SOURCE CHIROPRACTIC & PHYSICAL MEDICINE CENTER INC
Entity Type:Organization
Organization Name:1 SOURCE CHIROPRACTIC & PHYSICAL MEDICINE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:SANTANA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-448-2222
Mailing Address - Street 1:2718 LETAP CT
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-7218
Mailing Address - Country:US
Mailing Address - Phone:813-448-2222
Mailing Address - Fax:813-948-7111
Practice Address - Street 1:2718 LETAP CT
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-7218
Practice Address - Country:US
Practice Address - Phone:813-448-2222
Practice Address - Fax:813-948-7111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8357111N00000X
FLME1149622081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty