Provider Demographics
NPI:1558496398
Name:COLONIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:COLONIAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:EAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-894-9984
Mailing Address - Street 1:717 ALTALOMA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4158
Mailing Address - Country:US
Mailing Address - Phone:407-894-9984
Mailing Address - Fax:407-541-2015
Practice Address - Street 1:717 ALTALOMA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4158
Practice Address - Country:US
Practice Address - Phone:407-894-9984
Practice Address - Fax:407-541-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC4037111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty