1336471572 NPI number — CHIRO-MEDICAL OF WEST FT. LAUDERDALE, INC.

Table of content: (NPI 1336471572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336471572 NPI number — CHIRO-MEDICAL OF WEST FT. LAUDERDALE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIRO-MEDICAL OF WEST FT. LAUDERDALE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336471572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
731 NE 32ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-6918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-367-1333
Provider Business Mailing Address Fax Number:
561-367-1320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 W OAKLAND PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE A-23
Provider Business Practice Location Address City Name:
OAKLAND PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33311-1243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-367-1333
Provider Business Practice Location Address Fax Number:
561-367-1320
Provider Enumeration Date:
02/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PELLEGRINO
Authorized Official First Name:
SAL
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
561-367-1333

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH5659 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: CH6264 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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