Provider Demographics
NPI:1457660821
Name:FLORIDA INJURY LONGWOOD, LLC
Entity Type:Organization
Organization Name:FLORIDA INJURY LONGWOOD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:ANICIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:VICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-367-5160
Mailing Address - Street 1:6220 S. ORANGE BLOSSOM TRAIL
Mailing Address - Street 2:SUITE 197
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809
Mailing Address - Country:US
Mailing Address - Phone:407-367-5160
Mailing Address - Fax:407-367-5175
Practice Address - Street 1:410 S. RONALD REAGAN BOULEVARD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750
Practice Address - Country:US
Practice Address - Phone:407-379-1330
Practice Address - Fax:407-379-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7962111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty