Provider Demographics
NPI:1457594673
Name:CHIROPRACTIC AND SPORTS REHABILITATION INSTITUTE
Entity type:Organization
Organization Name:CHIROPRACTIC AND SPORTS REHABILITATION INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:RUDNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-271-3524
Mailing Address - Street 1:8794 BOYNTON BEACH BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8794 BOYNTON BEACH BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-4423
Practice Address - Country:US
Practice Address - Phone:561-271-3524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9514111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70328Medicare PIN