Provider Demographics
NPI:1972875284
Name:POULOS CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:POULOS CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-904-6066
Mailing Address - Street 1:727 NORTHLAKE BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-5242
Mailing Address - Country:US
Mailing Address - Phone:561-904-6066
Mailing Address - Fax:
Practice Address - Street 1:727 NORTHLAKE BLVD STE 4
Practice Address - Street 2:
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-5242
Practice Address - Country:US
Practice Address - Phone:561-904-6066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty