Provider Demographics
NPI:1477907079
Name:IMAGE CHIROPRACTIC RE-HAB LLC
Entity Type:Organization
Organization Name:IMAGE CHIROPRACTIC RE-HAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:VALLES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-707-1798
Mailing Address - Street 1:4048 EVANS AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9385
Mailing Address - Country:US
Mailing Address - Phone:239-362-3111
Mailing Address - Fax:
Practice Address - Street 1:4048 EVANS AVE STE 208
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9385
Practice Address - Country:US
Practice Address - Phone:239-362-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8452111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty