Provider Demographics
NPI:1891004065
Name:FLORIDA PROFESSIONAL CHIROPRACTIC
Entity Type:Organization
Organization Name:FLORIDA PROFESSIONAL CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:FARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-676-2225
Mailing Address - Street 1:100 S SCENIC HWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3827
Mailing Address - Country:US
Mailing Address - Phone:863-676-2225
Mailing Address - Fax:863-676-0698
Practice Address - Street 1:100 S SCENIC HWY
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3827
Practice Address - Country:US
Practice Address - Phone:863-676-2225
Practice Address - Fax:863-676-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22846Medicare PIN
FLU39492Medicare UPIN