Provider Demographics
NPI:1992219141
Name:DR. BROOKE IWANSKI DC LLC
Entity Type:Organization
Organization Name:DR. BROOKE IWANSKI DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:IWANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-791-4172
Mailing Address - Street 1:1791 BOY SCOUT DR STE 6
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-2137
Mailing Address - Country:US
Mailing Address - Phone:239-332-2555
Mailing Address - Fax:239-332-2556
Practice Address - Street 1:1791 BOY SCOUT DR STE 6
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2137
Practice Address - Country:US
Practice Address - Phone:239-332-2555
Practice Address - Fax:239-332-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10604111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007632300Medicaid