Provider Demographics
NPI:1477876472
Name:WISE CHIROPRACTIC PA
Entity Type:Organization
Organization Name:WISE CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-259-2225
Mailing Address - Street 1:17941 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6717
Mailing Address - Country:US
Mailing Address - Phone:352-516-6820
Mailing Address - Fax:
Practice Address - Street 1:17941 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6717
Practice Address - Country:US
Practice Address - Phone:352-516-6820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL431001936418001OtherCCN