Provider Demographics
NPI:1841755907
Name:COCOA CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:COCOA CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-636-6090
Mailing Address - Street 1:111 N FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7211
Mailing Address - Country:US
Mailing Address - Phone:321-636-6090
Mailing Address - Fax:321-632-5805
Practice Address - Street 1:111 N FISKE BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7211
Practice Address - Country:US
Practice Address - Phone:321-636-6090
Practice Address - Fax:321-632-5805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-04
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639143118OtherCHIROPRACTOR
FL1093051815OtherCHIROPRACTOR