Provider Demographics
NPI:1770139933
Name:COLONIAL CHIROPRACTIC, INC
Entity type:Organization
Organization Name:COLONIAL CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:VASCONCELLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-936-2144
Mailing Address - Street 1:1570 COLONIAL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1031
Mailing Address - Country:US
Mailing Address - Phone:239-936-2144
Mailing Address - Fax:239-936-7276
Practice Address - Street 1:1570 COLONIAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1031
Practice Address - Country:US
Practice Address - Phone:239-936-2144
Practice Address - Fax:239-936-7276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty