Provider Demographics
NPI:1780801761
Name:OVERLEA-FULLERTON CHIROPRACTIC CENTER PC
Entity type:Organization
Organization Name:OVERLEA-FULLERTON CHIROPRACTIC CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-994-6008
Mailing Address - Street 1:5317 VILLAGE MARKET DRIVE
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544
Mailing Address - Country:US
Mailing Address - Phone:813-994-6008
Mailing Address - Fax:813-994-3063
Practice Address - Street 1:5317 VILLAGE MARKET DRIVE
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544
Practice Address - Country:US
Practice Address - Phone:813-994-6008
Practice Address - Fax:813-994-3063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH006174111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271773OtherWELLCARE PRVD#
FL89273OtherBCBS PRVD#
FL295986OtherAVMED PRVD#
FL593466707OtherCHIRO ALLIANCE #
FLCH006174OtherSTATE LICENSE #
FL381806300Medicaid
FL381806300Medicaid
FL295986OtherAVMED PRVD#
FLCH006174OtherSTATE LICENSE #
FL89273ZMedicare PIN