Provider Demographics
NPI:1457629552
Name:LAFAYETTE CHIROPRACTIC CLINIC PA
Entity Type:Organization
Organization Name:LAFAYETTE CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:ELKJAER
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-222-2952
Mailing Address - Street 1:1844 FIDDLER CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4450
Mailing Address - Country:US
Mailing Address - Phone:850-222-2952
Mailing Address - Fax:850-877-0845
Practice Address - Street 1:1844 FIDDLER CT
Practice Address - Street 2:SUITE B
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4450
Practice Address - Country:US
Practice Address - Phone:850-222-2952
Practice Address - Fax:850-877-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty