Provider Demographics
NPI:1134393804
Name:PREMIER CHIROPRACTIC AND WELLNESS CENTER PLC
Entity type:Organization
Organization Name:PREMIER CHIROPRACTIC AND WELLNESS CENTER PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-996-6922
Mailing Address - Street 1:3500 BEACHWOOD CT
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-5706
Mailing Address - Country:US
Mailing Address - Phone:904-996-6922
Mailing Address - Fax:904-996-6923
Practice Address - Street 1:3500 BEACHWOOD CT
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5706
Practice Address - Country:US
Practice Address - Phone:904-996-6922
Practice Address - Fax:904-996-6923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8655171100000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889041OtherBCBS
FL89041AMedicare PIN