Provider Demographics
NPI:1942275623
Name:CLITES, RAYMOND DALE JR (DC)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:DALE
Last Name:CLITES
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 W BRANDON BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4731
Mailing Address - Country:US
Mailing Address - Phone:813-684-1648
Mailing Address - Fax:813-684-1748
Practice Address - Street 1:2119 W BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4731
Practice Address - Country:US
Practice Address - Phone:813-684-1648
Practice Address - Fax:813-684-1748
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 4571111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380271000Medicaid
FL70474Medicare ID - Type Unspecified
FL380271000Medicaid