Provider Demographics
NPI:1710538319
Name:FIRST STATE SPINAL REHABILITATION LLC
Entity Type:Organization
Organization Name:FIRST STATE SPINAL REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENEANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WAKULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-546-9591
Mailing Address - Street 1:9044 SE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-5313
Mailing Address - Country:US
Mailing Address - Phone:772-546-9591
Mailing Address - Fax:772-546-9535
Practice Address - Street 1:2500 W 4TH ST STE 4
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3352
Practice Address - Country:US
Practice Address - Phone:772-546-9591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty