Provider Demographics
NPI:1396032793
Name:FLORIDA SPINE & REHAB CENTER, LLC
Entity Type:Organization
Organization Name:FLORIDA SPINE & REHAB CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TRUDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-772-2225
Mailing Address - Street 1:483 N. SEMORAN BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4549
Mailing Address - Country:US
Mailing Address - Phone:407-772-2225
Mailing Address - Fax:407-772-0302
Practice Address - Street 1:483 N SEMORAN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3800
Practice Address - Country:US
Practice Address - Phone:407-772-2225
Practice Address - Fax:407-772-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7566111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1235252537OtherNPI