Provider Demographics
NPI:1437409885
Name:FORT WALTON BEACH CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:FORT WALTON BEACH CHIROPRACTIC LLC
Other - Org Name:FORT WALTON BEACH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-200-4911
Mailing Address - Street 1:315 RACETRACK RD NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-2548
Mailing Address - Country:US
Mailing Address - Phone:850-200-4911
Mailing Address - Fax:
Practice Address - Street 1:315 RACETRACK RD NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-2548
Practice Address - Country:US
Practice Address - Phone:850-200-4911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty