Provider Demographics
NPI:1275714644
Name:CORAL RIDGE CHIROPRRACTIC
Entity Type:Organization
Organization Name:CORAL RIDGE CHIROPRRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-630-1616
Mailing Address - Street 1:2745 E OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1635
Mailing Address - Country:US
Mailing Address - Phone:956-363-0161
Mailing Address - Fax:954-656-1365
Practice Address - Street 1:2745 E OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1635
Practice Address - Country:US
Practice Address - Phone:956-363-0161
Practice Address - Fax:954-656-1365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8419111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU66946Medicare UPIN