Provider Demographics
NPI:1184991127
Name:RADIANT HEALTH CHIROPRACTIC LLC
Entity type:Organization
Organization Name:RADIANT HEALTH CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-308-9076
Mailing Address - Street 1:209 DUNLAWTON AVE STE 18
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4458
Mailing Address - Country:US
Mailing Address - Phone:386-308-9076
Mailing Address - Fax:386-675-6591
Practice Address - Street 1:209 DUNLAWTON AVE STE 18
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4458
Practice Address - Country:US
Practice Address - Phone:386-308-9076
Practice Address - Fax:386-675-6591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9993111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007930500Medicaid
FL007930500Medicaid