Provider Demographics
NPI:1245413459
Name:MAURICIO CHIROPRACTIC EAST COLONIAL, LLC
Entity Type:Organization
Organization Name:MAURICIO CHIROPRACTIC EAST COLONIAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-381-0878
Mailing Address - Street 1:12278 E. COLONIAL DRIVE
Mailing Address - Street 2:STE 600
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826
Mailing Address - Country:US
Mailing Address - Phone:407-381-0878
Mailing Address - Fax:407-373-6046
Practice Address - Street 1:12278 E. COLONIAL DRIVE
Practice Address - Street 2:STE 700
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826
Practice Address - Country:US
Practice Address - Phone:407-273-7727
Practice Address - Fax:407-273-7718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7915AMedicaid