Provider Demographics
NPI:1629258330
Name:MAURICIO CHIROPRACTIC GROUP INC
Entity Type:Organization
Organization Name:MAURICIO CHIROPRACTIC GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-381-0878
Mailing Address - Street 1:12278 E. COLONIAL DR.
Mailing Address - Street 2:STE #600B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826
Mailing Address - Country:US
Mailing Address - Phone:407-381-0878
Mailing Address - Fax:407-373-6046
Practice Address - Street 1:4747 S. CONWAY ROAD
Practice Address - Street 2:STE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812
Practice Address - Country:US
Practice Address - Phone:407-240-8430
Practice Address - Fax:407-438-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22012Medicare PIN