Provider Demographics
NPI:1528202611
Name:CONLON CHIROPRACTIC
Entity Type:Organization
Organization Name:CONLON CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONLON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-335-3660
Mailing Address - Street 1:1775 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5479
Mailing Address - Country:US
Mailing Address - Phone:772-335-3660
Mailing Address - Fax:772-335-3663
Practice Address - Street 1:1775 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5479
Practice Address - Country:US
Practice Address - Phone:772-335-3660
Practice Address - Fax:772-335-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53919OtherBLUE CROSS/BLUE SHIELD
FL53919ZMedicare PIN