Provider Demographics
NPI:1356090245
Name:PORT CHARLOTTE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:PORT CHARLOTTE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:815-252-9783
Mailing Address - Street 1:795 CRESTVIEW CIR NW
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-2126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:795 CRESTVIEW CIR NW
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2126
Practice Address - Country:US
Practice Address - Phone:941-629-8444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-20
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty