Provider Demographics
NPI:1245751338
Name:VITAL WAVE CHIROPRACTIC
Entity type:Organization
Organization Name:VITAL WAVE CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-884-0704
Mailing Address - Street 1:909 NE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3037
Mailing Address - Country:US
Mailing Address - Phone:954-884-0704
Mailing Address - Fax:
Practice Address - Street 1:909 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3037
Practice Address - Country:US
Practice Address - Phone:954-884-0704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12216111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty