Provider Demographics
NPI:1417403221
Name:AHAVA-5772, LLC
Entity Type:Organization
Organization Name:AHAVA-5772, LLC
Other - Org Name:NAMASTE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:KOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-596-2714
Mailing Address - Street 1:5540 PGA BOULEVARD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418
Mailing Address - Country:US
Mailing Address - Phone:561-596-2714
Mailing Address - Fax:
Practice Address - Street 1:5540 PGA BOULEVARD
Practice Address - Street 2:SUITE 100
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418
Practice Address - Country:US
Practice Address - Phone:561-596-2714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7712111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLES056ZOtherMEDICARE PTAN