Provider Demographics
NPI:1245371616
Name:FOGARTY CHIROPRACTIC LIFE CLINIC OF ORLANDO, PA
Entity type:Organization
Organization Name:FOGARTY CHIROPRACTIC LIFE CLINIC OF ORLANDO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-281-0707
Mailing Address - Street 1:12484 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7100
Mailing Address - Country:US
Mailing Address - Phone:407-281-0707
Mailing Address - Fax:407-273-4793
Practice Address - Street 1:12484 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7100
Practice Address - Country:US
Practice Address - Phone:407-281-0707
Practice Address - Fax:407-273-4793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381967100Medicaid