Provider Demographics
NPI:1437221819
Name:CHIROPRACTIC BACK PAIN CLINIC
Entity Type:Organization
Organization Name:CHIROPRACTIC BACK PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:P
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:305-774-6923
Mailing Address - Street 1:1029 MALAGA AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-6318
Mailing Address - Country:US
Mailing Address - Phone:305-448-8251
Mailing Address - Fax:
Practice Address - Street 1:2645 SW 37TH AVE
Practice Address - Street 2:SUITE 704
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-2754
Practice Address - Country:US
Practice Address - Phone:305-774-1119
Practice Address - Fax:305-774-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6723111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU49236Medicare UPIN
FL22998Medicare ID - Type Unspecified