Provider Demographics
NPI:1891053294
Name:BAIN DE VIE CORY LAKE ISLE LLC
Entity Type:Organization
Organization Name:BAIN DE VIE CORY LAKE ISLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:FILMORE
Authorized Official - Last Name:BAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-907-9898
Mailing Address - Street 1:10311 CROSS CREEK BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2989
Mailing Address - Country:US
Mailing Address - Phone:813-907-9898
Mailing Address - Fax:813-907-0220
Practice Address - Street 1:10311 CROSS CREEK BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2989
Practice Address - Country:US
Practice Address - Phone:813-907-9898
Practice Address - Fax:813-907-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty