Provider Demographics
NPI:1275857385
Name:TIMOTHY DOUGLASS DC PA
Entity Type:Organization
Organization Name:TIMOTHY DOUGLASS DC PA
Other - Org Name:DOUGLASS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-650-6789
Mailing Address - Street 1:4421 COMMONS DR E
Mailing Address - Street 2:# B-105
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3484
Mailing Address - Country:US
Mailing Address - Phone:850-650-6789
Mailing Address - Fax:850-650-6790
Practice Address - Street 1:4221 COMMONS DR EAST
Practice Address - Street 2:STE B-105
Practice Address - City:DESTON
Practice Address - State:FL
Practice Address - Zip Code:32541-3483
Practice Address - Country:US
Practice Address - Phone:850-650-6789
Practice Address - Fax:850-650-6790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty