Provider Demographics
NPI:1124442702
Name:MICELI, TRISTAN (DC)
Entity type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:
Last Name:MICELI
Suffix:
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 1:129 S STATE ROAD 7 STE 402
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4379
Mailing Address - Country:US
Mailing Address - Phone:561-469-6699
Mailing Address - Fax:561-469-6636
Practice Address - Street 1:129 S STATE ROAD 7 STE 402
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4379
Practice Address - Country:US
Practice Address - Phone:561-469-6699
Practice Address - Fax:561-469-6636
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor