Provider Demographics
NPI:1760780043
Name:BALLISTREA FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BALLISTREA FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALLISTREA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-868-4444
Mailing Address - Street 1:7236 STATE ROAD 52
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BAYONET POINT
Mailing Address - State:FL
Mailing Address - Zip Code:34667-6749
Mailing Address - Country:US
Mailing Address - Phone:727-868-4444
Mailing Address - Fax:727-868-2892
Practice Address - Street 1:7236 STATE ROAD 52
Practice Address - Street 2:SUITE 3
Practice Address - City:BAYONET POINT
Practice Address - State:FL
Practice Address - Zip Code:34667-6749
Practice Address - Country:US
Practice Address - Phone:727-868-4444
Practice Address - Fax:727-868-2892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8075111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Single Specialty