Provider Demographics
NPI:1679673396
Name:PALM COAST CHIROPRACTIC CENTER, JTA INC
Entity Type:Organization
Organization Name:PALM COAST CHIROPRACTIC CENTER, JTA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-437-7111
Mailing Address - Street 1:4721 E MOODY BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-7706
Mailing Address - Country:US
Mailing Address - Phone:386-437-7111
Mailing Address - Fax:386-437-7790
Practice Address - Street 1:4721 E MOODY BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-7706
Practice Address - Country:US
Practice Address - Phone:386-437-7111
Practice Address - Fax:386-437-7790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV08423Medicare UPIN
U69816Medicare UPIN