Provider Demographics
NPI:1598203283
Name:RAYMOND G NIETZOLD DC, PA
Entity Type:Organization
Organization Name:RAYMOND G NIETZOLD DC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:NIETZOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-585-4488
Mailing Address - Street 1:1745 S HIGHLAND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-1852
Mailing Address - Country:US
Mailing Address - Phone:727-585-4488
Mailing Address - Fax:
Practice Address - Street 1:1745 S HIGHLAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-1852
Practice Address - Country:US
Practice Address - Phone:727-585-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004038111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88858Medicare UPIN