Provider Demographics
NPI:1891383444
Name:ST. JOHNS CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:ST. JOHNS CHIROPRACTIC, LLC
Other - Org Name:ST. JOHNS SPORT AND SPINE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHASE
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:VANDERPOL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-319-7397
Mailing Address - Street 1:14724 BULOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1173
Mailing Address - Country:US
Mailing Address - Phone:904-290-1312
Mailing Address - Fax:
Practice Address - Street 1:155 BARTRAM MARKET DR STE 113
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4582
Practice Address - Country:US
Practice Address - Phone:904-290-1312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-08
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty