Provider Demographics
NPI:1619278447
Name:FOGARTY CHIROPRACTIC LIFE CLINIC PA
Entity Type:Organization
Organization Name:FOGARTY CHIROPRACTIC LIFE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:321-636-5200
Mailing Address - Street 1:839 BARTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3127
Mailing Address - Country:US
Mailing Address - Phone:321-636-5200
Mailing Address - Fax:321-639-0418
Practice Address - Street 1:839 BARTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3127
Practice Address - Country:US
Practice Address - Phone:321-636-5200
Practice Address - Fax:321-639-0418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty