Provider Demographics
NPI:1326534058
Name:NEW WAVE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:NEW WAVE CHIROPRACTIC LLC
Other - Org Name:WILD LIFE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:SHIVER
Authorized Official - Last Name:MINCEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-750-8850
Mailing Address - Street 1:3150 N WICKHAM RD STE 5
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2322
Mailing Address - Country:US
Mailing Address - Phone:321-750-8850
Mailing Address - Fax:321-256-5243
Practice Address - Street 1:3150 N WICKHAM RD STE 5
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2322
Practice Address - Country:US
Practice Address - Phone:321-750-8850
Practice Address - Fax:321-256-5243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12446111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty