Provider Demographics
NPI:1942673223
Name:TRADITION FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:TRADITION FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:JITTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-933-8260
Mailing Address - Street 1:10552 SW VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2359
Mailing Address - Country:US
Mailing Address - Phone:954-933-8260
Mailing Address - Fax:
Practice Address - Street 1:10552 SW VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2359
Practice Address - Country:US
Practice Address - Phone:954-933-8260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty