Provider Demographics
NPI:1245318492
Name:WAKEMAN CHIROPRACTIC , PA
Entity type:Organization
Organization Name:WAKEMAN CHIROPRACTIC , PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAKEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-673-0201
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 305
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5169
Mailing Address - Country:US
Mailing Address - Phone:386-673-0201
Mailing Address - Fax:386-677-8143
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 305
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-673-0201
Practice Address - Fax:386-677-8143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5831111N00000X, 332B00000X
FLPT22240225100000X
FLCH1429332B00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDB4204OtherRAILROAD MEDICARE GROUP PIN
FL74592OtherBCBS GROUP NUMBER
FL74592OtherBCBS GROUP NUMBER
FL6487700001Medicare NSC