Provider Demographics
NPI:1881360642
Name:OLD KINGS CHIROPRACTIC LLC
Entity type:Organization
Organization Name:OLD KINGS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SAMBURSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-693-4095
Mailing Address - Street 1:99 OLD KINGS RD S STE 4
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-4356
Mailing Address - Country:US
Mailing Address - Phone:386-693-4095
Mailing Address - Fax:866-711-2736
Practice Address - Street 1:99 OLD KINGS RD S STE 4
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-4356
Practice Address - Country:US
Practice Address - Phone:386-693-4095
Practice Address - Fax:866-711-2736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty