Provider Demographics
NPI:1558628123
Name:WIDOM CHIROPRACTIC OFFICES PA
Entity Type:Organization
Organization Name:WIDOM CHIROPRACTIC OFFICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:WIDOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-263-3332
Mailing Address - Street 1:5385 PARK CENTRAL CT
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-5932
Mailing Address - Country:US
Mailing Address - Phone:239-596-9050
Mailing Address - Fax:
Practice Address - Street 1:5385 PARK CENTRAL CT
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-5932
Practice Address - Country:US
Practice Address - Phone:239-596-9050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 6230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty