Provider Demographics
NPI:1417143496
Name:PINE ISLAND CHIROPRACTIC INC
Entity Type:Organization
Organization Name:PINE ISLAND CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARELL
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-282-0255
Mailing Address - Street 1:5781 BAYSHORE ROAD
Mailing Address - Street 2:#103
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917
Mailing Address - Country:US
Mailing Address - Phone:239-282-0255
Mailing Address - Fax:844-693-2782
Practice Address - Street 1:5781 BAYSHORE ROAD
Practice Address - Street 2:#103
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33917
Practice Address - Country:US
Practice Address - Phone:239-282-0255
Practice Address - Fax:844-693-2782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8741111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV01614Medicare UPIN
FLK6383Medicare PIN