Provider Demographics
NPI:1508153453
Name:JA CANTU SERVICE GROUP LLC
Entity Type:Organization
Organization Name:JA CANTU SERVICE GROUP LLC
Other - Org Name:CHIROPRACTIC OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:434-295-4367
Mailing Address - Street 1:1911 COMMONWEALTH DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-2338
Mailing Address - Country:US
Mailing Address - Phone:434-295-4367
Mailing Address - Fax:434-971-9733
Practice Address - Street 1:1911 COMMONWEALTH DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-2338
Practice Address - Country:US
Practice Address - Phone:434-295-4367
Practice Address - Fax:434-971-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555910111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA412Medicare PIN