Provider Demographics
NPI:1467652578
Name:COLUMBIA COUNTY CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:COLUMBIA COUNTY CHIROPRACTIC CENTER, LLC
Other - Org Name:DARREL THOMAS MATHIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-752-4313
Mailing Address - Street 1:279 SW MAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-7050
Mailing Address - Country:US
Mailing Address - Phone:386-752-4313
Mailing Address - Fax:386-752-8356
Practice Address - Street 1:279 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-7050
Practice Address - Country:US
Practice Address - Phone:386-752-4313
Practice Address - Fax:386-752-8356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5141111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050782200Medicaid
FLCL2214OtherRAILROAD MEDICARE GROUP #
FLCL2214OtherRAILROAD MEDICARE GROUP #