Provider Demographics
NPI:1245241553
Name:CHARLES VICKERS DC PA
Entity Type:Organization
Organization Name:CHARLES VICKERS DC PA
Other - Org Name:VICKERS CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-644-5541
Mailing Address - Street 1:4325 HIGHLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1671
Mailing Address - Country:US
Mailing Address - Phone:863-644-5541
Mailing Address - Fax:863-647-1793
Practice Address - Street 1:4325 HIGHLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1671
Practice Address - Country:US
Practice Address - Phone:863-644-5541
Practice Address - Fax:863-647-1793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003329111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051926000Medicaid
FL88408Medicare ID - Type Unspecified
FL051926000Medicaid