Provider Demographics
NPI:1972930691
Name:UMATILLA CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:UMATILLA CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-459-6411
Mailing Address - Street 1:533 UMATILLA BLVD
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-9091
Mailing Address - Country:US
Mailing Address - Phone:352-459-6411
Mailing Address - Fax:352-387-7888
Practice Address - Street 1:533 UMATILLA BLVD
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-9091
Practice Address - Country:US
Practice Address - Phone:352-459-6411
Practice Address - Fax:352-387-7888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9512261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V05774Medicare UPIN