Provider Demographics
NPI:1457511172
Name:LEV SUDAKOV DC PA
Entity Type:Organization
Organization Name:LEV SUDAKOV DC PA
Other - Org Name:OCEAN DRIVE CHIROPRACTIC & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEV
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-391-7864
Mailing Address - Street 1:3800 S OCEAN DR STE 230
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-2930
Mailing Address - Country:US
Mailing Address - Phone:954-391-7864
Mailing Address - Fax:954-391-8468
Practice Address - Street 1:3800 S OCEAN DR STE 230
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33019-2930
Practice Address - Country:US
Practice Address - Phone:954-391-7864
Practice Address - Fax:954-391-8468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8450111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000170100Medicaid
FLAL792Medicare UPIN