Provider Demographics
NPI:1639463516
Name:WANDA I. NIEVES-MORENO, DC, LLC
Entity Type:Organization
Organization Name:WANDA I. NIEVES-MORENO, DC, LLC
Other - Org Name:BRANDON CHIROPRACTIC AND MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:I
Authorized Official - Last Name:NIEVES-MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-685-5200
Mailing Address - Street 1:654 E BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8111
Mailing Address - Country:US
Mailing Address - Phone:813-685-5200
Mailing Address - Fax:813-654-8758
Practice Address - Street 1:654 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8111
Practice Address - Country:US
Practice Address - Phone:813-685-5200
Practice Address - Fax:813-654-8758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty