Provider Demographics
NPI:1477826840
Name:1SPINE CHIROPRACTIC AND REHABILITATION OLDSMAR
Entity type:Organization
Organization Name:1SPINE CHIROPRACTIC AND REHABILITATION OLDSMAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-220-0680
Mailing Address - Street 1:3687 TAMPA RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-6307
Mailing Address - Country:US
Mailing Address - Phone:813-220-0680
Mailing Address - Fax:
Practice Address - Street 1:3687 TAMPA RD
Practice Address - Street 2:SUITE 202
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-6307
Practice Address - Country:US
Practice Address - Phone:813-220-0680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8383111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU94732Medicare PIN