Provider Demographics
NPI:1407154875
Name:CITRUS REGIONAL CLINIC OF CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:CITRUS REGIONAL CLINIC OF CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-344-1300
Mailing Address - Street 1:108 W HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4819
Mailing Address - Country:US
Mailing Address - Phone:352-344-1300
Mailing Address - Fax:352-341-4500
Practice Address - Street 1:108 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4819
Practice Address - Country:US
Practice Address - Phone:352-344-1300
Practice Address - Fax:352-341-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8687111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty