Provider Demographics
NPI:1588846505
Name:VITAL CHIROPRACTIC WELLNESS CENTER PA
Entity Type:Organization
Organization Name:VITAL CHIROPRACTIC WELLNESS CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUKEYSER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-232-4091
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34991-0357
Mailing Address - Country:US
Mailing Address - Phone:772-232-4091
Mailing Address - Fax:772-232-4092
Practice Address - Street 1:3543 SW CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-8151
Practice Address - Country:US
Practice Address - Phone:772-232-4091
Practice Address - Fax:772-232-4092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8946111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94993Medicare PIN