Provider Demographics
NPI:1659504553
Name:DELTONA CHIROPRACTIC & ADVANCED PAIN MANAGEMENT CENTER, LLC
Entity Type:Organization
Organization Name:DELTONA CHIROPRACTIC & ADVANCED PAIN MANAGEMENT CENTER, LLC
Other - Org Name:DELTONA ADVANCED MEDICAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAULK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-846-4588
Mailing Address - Street 1:1240 E NORMANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8484
Mailing Address - Country:US
Mailing Address - Phone:386-574-1464
Mailing Address - Fax:386-574-4895
Practice Address - Street 1:1240 E NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-8484
Practice Address - Country:US
Practice Address - Phone:386-574-1464
Practice Address - Fax:386-574-4895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty