Provider Demographics
NPI:1770785412
Name:NEW SMYRNA BEACH CHIROPRACTIC CLINIC PLC
Entity type:Organization
Organization Name:NEW SMYRNA BEACH CHIROPRACTIC CLINIC PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:PROKOP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-423-5259
Mailing Address - Street 1:1205 N DIXIE FWY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6005
Mailing Address - Country:US
Mailing Address - Phone:386-423-5259
Mailing Address - Fax:386-423-0929
Practice Address - Street 1:1205 N DIXIE FWY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6005
Practice Address - Country:US
Practice Address - Phone:386-423-5259
Practice Address - Fax:386-423-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9205111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty