Provider Demographics
NPI:1306418678
Name:MAWN CHIROPRACTIC PA
Entity Type:Organization
Organization Name:MAWN CHIROPRACTIC PA
Other - Org Name:THE SOURCE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DYLLON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAWN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-876-2157
Mailing Address - Street 1:5751 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-5021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8702
Practice Address - Country:US
Practice Address - Phone:727-329-6106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty