Provider Demographics
NPI:1669645057
Name:AMERICAN FAMILY & SPORTS CHIROPRACTIC CENTER INC
Entity Type:Organization
Organization Name:AMERICAN FAMILY & SPORTS CHIROPRACTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:HENNIGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-760-6150
Mailing Address - Street 1:4649 CLYDE MORRIS BLVD UNIT 609
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-3003
Mailing Address - Country:US
Mailing Address - Phone:386-760-6150
Mailing Address - Fax:386-788-1998
Practice Address - Street 1:4649 CLYDE MORRIS BLVD UNIT 609
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-760-6150
Practice Address - Fax:386-788-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL382037800Medicaid
FLU82888/0001Medicare UPIN