Provider Demographics
NPI:1568749992
Name:WATERFORD LAKES WELLNESS AND INJURY INC
Entity Type:Organization
Organization Name:WATERFORD LAKES WELLNESS AND INJURY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NAHALI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-277-5555
Mailing Address - Street 1:11333 LAKE UNDERHILL RD
Mailing Address - Street 2:SUITE. 105
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5091
Mailing Address - Country:US
Mailing Address - Phone:407-277-5555
Mailing Address - Fax:
Practice Address - Street 1:11333 LAKE UNDERHILL RD
Practice Address - Street 2:SUITE. 105
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-5091
Practice Address - Country:US
Practice Address - Phone:407-277-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERFORD LAKES WELLNESS AND INJURY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8054111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU85246 0001Medicare UPIN
FL00070206AMedicare PIN