Provider Demographics
NPI:1609153311
Name:GARY K STOLTZ, D.C., P.A.
Entity Type:Organization
Organization Name:GARY K STOLTZ, D.C., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:STOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-357-7955
Mailing Address - Street 1:2105 PREVATT ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6131
Mailing Address - Country:US
Mailing Address - Phone:352-357-7955
Mailing Address - Fax:352-357-7254
Practice Address - Street 1:2105 PREVATT ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6131
Practice Address - Country:US
Practice Address - Phone:352-357-7955
Practice Address - Fax:352-357-7254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH2081111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL350907427OtherRR MEDICARE
FLCH2081OtherSTATE LICENCE ID- WORK COMP
FL380263900Medicaid
FL89727Medicare PIN
FL380263900Medicaid