Provider Demographics
NPI:1659505550
Name:FOUR CORNERS REHAB & WELLNESS PL
Entity Type:Organization
Organization Name:FOUR CORNERS REHAB & WELLNESS PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-852-2600
Mailing Address - Street 1:39857 HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7802
Mailing Address - Country:US
Mailing Address - Phone:863-852-2600
Mailing Address - Fax:
Practice Address - Street 1:39857 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7802
Practice Address - Country:US
Practice Address - Phone:863-852-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty