Provider Demographics
NPI:1134252471
Name:WATT FAMILY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:WATT FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:WATT
Authorized Official - Suffix:
Authorized Official - Credentials:BS, DC
Authorized Official - Phone:321-253-8511
Mailing Address - Street 1:2255 N. WICKHAM RD #109
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935
Mailing Address - Country:US
Mailing Address - Phone:321-253-8511
Mailing Address - Fax:321-253-8711
Practice Address - Street 1:2255 N. WICKHAM RD #109
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-253-8511
Practice Address - Fax:321-253-8711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8029111N00000X
FLCH7835111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381734200Medicaid