Provider Demographics
NPI:1508167081
Name:PROBECK CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:PROBECK CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:PROBECK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-384-2611
Mailing Address - Street 1:5627 GULFPORT BLVD S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4828
Mailing Address - Country:US
Mailing Address - Phone:727-384-2611
Mailing Address - Fax:727-343-3865
Practice Address - Street 1:5627 GULFPORT BLVD S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-4828
Practice Address - Country:US
Practice Address - Phone:727-384-2611
Practice Address - Fax:727-343-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3731111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381512900Medicaid
T55938Medicare UPIN
88724Medicare PIN