Provider Demographics
NPI:1477721918
Name:ROD DAVIS CHIROPRACTIC P A
Entity type:Organization
Organization Name:ROD DAVIS CHIROPRACTIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:F
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-699-0111
Mailing Address - Street 1:155 E INTERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-9578
Mailing Address - Country:US
Mailing Address - Phone:863-699-0111
Mailing Address - Fax:863-699-1046
Practice Address - Street 1:155 E INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9578
Practice Address - Country:US
Practice Address - Phone:863-699-0111
Practice Address - Fax:863-699-1046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007552111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280013600Medicaid
FLU90292Medicare UPIN
FL280013600Medicaid