Provider Demographics
NPI: | 1467840769 |
---|---|
Name: | SWANN MEDICAL |
Entity Type: | Organization |
Organization Name: | SWANN MEDICAL |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CO-OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | O'HARA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MCKENNA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 678-923-5315 |
Mailing Address - Street 1: | 2111 W SWANN AVE |
Mailing Address - Street 2: | SUITE 104 |
Mailing Address - City: | TAMPA |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33606-2477 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 813-253-5969 |
Mailing Address - Fax: | 813-253-5848 |
Practice Address - Street 1: | 2111 W SWANN AVE |
Practice Address - Street 2: | SUITE 104 |
Practice Address - City: | TAMPA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33606-2477 |
Practice Address - Country: | US |
Practice Address - Phone: | 813-253-5969 |
Practice Address - Fax: | 813-253-5848 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-01-08 |
Last Update Date: | 2015-01-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | CH9435 | 111N00000X |
FL | CH11379 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty |