Provider Demographics
NPI:1780006403
Name:PURE CHIROPRACTIC & NATURAL HEALTH, PA
Entity Type:Organization
Organization Name:PURE CHIROPRACTIC & NATURAL HEALTH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-682-4454
Mailing Address - Street 1:200 WAYMONT CT
Mailing Address - Street 2:SUITE 126, UNIT #3
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3413
Mailing Address - Country:US
Mailing Address - Phone:407-682-4454
Mailing Address - Fax:407-682-3805
Practice Address - Street 1:200 WAYMONT CT
Practice Address - Street 2:SUITE 126, UNIT #3
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3413
Practice Address - Country:US
Practice Address - Phone:407-682-4454
Practice Address - Fax:407-682-3805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3063111N00000X, 111NI0013X, 133N00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1194299950OtherSTATE OF OHIO WORKER'S COMPENSATION
FLCH3063OtherSTATE OF FLORIDA WORKER'S COMPENSATION
FL88322AOtherBLUE CROSSS & BLUE SHIELD
FL88322AOtherBLUE CROSSS & BLUE SHIELD