Provider Demographics
NPI:1821421363
Name:EDGEWATER CHIROPRACTIC CLINIC, P.A.
Entity Type:Organization
Organization Name:EDGEWATER CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:KRISTEEN
Authorized Official - Last Name:MECKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-423-7575
Mailing Address - Street 1:201 S RIDGEWOOD AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-1935
Mailing Address - Country:US
Mailing Address - Phone:386-423-7575
Mailing Address - Fax:
Practice Address - Street 1:201 S RIDGEWOOD AVE STE 11
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-1935
Practice Address - Country:US
Practice Address - Phone:386-423-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10882111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty