Provider Demographics
NPI:1790978989
Name:VINE FAMILY CHIROPRACTIC CENTRE
Entity Type:Organization
Organization Name:VINE FAMILY CHIROPRACTIC CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-935-1137
Mailing Address - Street 1:700 W VINE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4203
Mailing Address - Country:US
Mailing Address - Phone:407-935-1137
Mailing Address - Fax:407-935-1138
Practice Address - Street 1:700 W VINE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4203
Practice Address - Country:US
Practice Address - Phone:407-935-1137
Practice Address - Fax:407-935-1138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8173Medicare PIN