Provider Demographics
NPI:1609362904
Name:MCKENNEY CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:MCKENNEY CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-245-8955
Mailing Address - Street 1:5608 SE 113TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-4069
Mailing Address - Country:US
Mailing Address - Phone:352-245-8955
Mailing Address - Fax:
Practice Address - Street 1:5608 SE 113TH ST STE A
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4069
Practice Address - Country:US
Practice Address - Phone:352-245-8955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12516111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39615OtherBCBS
FL617149200OtherFEDERAL W/C
FL003069700Medicaid