Provider Demographics
NPI:1861685125
Name:CG1 CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:CG1 CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINADOR
Authorized Official - Middle Name:REYNO
Authorized Official - Last Name:UY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:813-909-7171
Mailing Address - Street 1:16102 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-6129
Mailing Address - Country:US
Mailing Address - Phone:813-909-7171
Mailing Address - Fax:
Practice Address - Street 1:16102 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6129
Practice Address - Country:US
Practice Address - Phone:813-909-7171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV05423Medicare UPIN
K7765Medicare PIN