Provider Demographics
NPI:1700288644
Name:SOUTH LAKELAND CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:SOUTH LAKELAND CHIROPRACTIC CENTER
Other - Org Name:NEW HOPE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IDA
Authorized Official - Middle Name:FAITH
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-682-1170
Mailing Address - Street 1:4788 S. FLORIDA AVE.
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-9812
Mailing Address - Country:US
Mailing Address - Phone:863-682-1170
Mailing Address - Fax:
Practice Address - Street 1:201 W CHRISTINA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-9812
Practice Address - Country:US
Practice Address - Phone:863-682-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10871111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty