Provider Demographics
NPI:1407380868
Name:TRUE VINE CHIROPRACTIC PA
Entity Type:Organization
Organization Name:TRUE VINE CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSTARZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-401-0915
Mailing Address - Street 1:6743 W INDIANTOWN RD STE 37
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-3987
Mailing Address - Country:US
Mailing Address - Phone:561-401-0915
Mailing Address - Fax:
Practice Address - Street 1:6743 W INDIANTOWN RD STE 37
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-3987
Practice Address - Country:US
Practice Address - Phone:561-401-0915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10901111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty