Provider Demographics
NPI:1295918548
Name:DEERWOOD LAKE CHIROPRACTIC
Entity type:Organization
Organization Name:DEERWOOD LAKE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-996-8660
Mailing Address - Street 1:4540 SOUTHSIDE BLVD
Mailing Address - Street 2:STE. # 1101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5492
Mailing Address - Country:US
Mailing Address - Phone:904-996-8660
Mailing Address - Fax:904-996-8650
Practice Address - Street 1:4540 SOUTHSIDE BLVD
Practice Address - Street 2:STE. # 1101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5492
Practice Address - Country:US
Practice Address - Phone:904-996-8660
Practice Address - Fax:904-996-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6864111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9716Medicare PIN