Provider Demographics
NPI:1063916914
Name:GRAND CHIROPRACTIC PA
Entity type:Organization
Organization Name:GRAND CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-849-5077
Mailing Address - Street 1:6145 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2605
Mailing Address - Country:US
Mailing Address - Phone:727-849-5077
Mailing Address - Fax:727-849-7901
Practice Address - Street 1:6145 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2605
Practice Address - Country:US
Practice Address - Phone:727-849-5077
Practice Address - Fax:727-849-7901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11708111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016179400Medicaid