Provider Demographics
NPI:1336497916
Name:SURFSIDE CHIROPRACTIC OF JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:SURFSIDE CHIROPRACTIC OF JACKSONVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:BAIATA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:917-204-4166
Mailing Address - Street 1:469 ATLANTIC BLVD
Mailing Address - Street 2:UNIT 8
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233
Mailing Address - Country:US
Mailing Address - Phone:904-241-8302
Mailing Address - Fax:
Practice Address - Street 1:469 ATLANTIC BLVD
Practice Address - Street 2:UNIT 8
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233
Practice Address - Country:US
Practice Address - Phone:904-241-8302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty