Provider Demographics
NPI:1497928121
Name:PORT ST. JOE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:PORT ST. JOE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-960-8118
Mailing Address - Street 1:16910 S US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8664
Mailing Address - Country:US
Mailing Address - Phone:850-960-8118
Mailing Address - Fax:352-347-9044
Practice Address - Street 1:16910 S US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8664
Practice Address - Country:US
Practice Address - Phone:850-960-8118
Practice Address - Fax:352-347-9044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU85018OtherUPIN
88546OtherBCBS
FL381798900Medicaid
FL381798900Medicaid