Provider Demographics
NPI:1407042781
Name:VILLAGE CHIROPRACTIC CENTER OF
Entity Type:Organization
Organization Name:VILLAGE CHIROPRACTIC CENTER OF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-940-0361
Mailing Address - Street 1:425 W TOWN PL
Mailing Address - Street 2:STE. 118
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3661
Mailing Address - Country:US
Mailing Address - Phone:904-940-0361
Mailing Address - Fax:904-940-0364
Practice Address - Street 1:425 W TOWN PL
Practice Address - Street 2:STE. 118
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3661
Practice Address - Country:US
Practice Address - Phone:904-940-0361
Practice Address - Fax:904-940-0364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty