Provider Demographics
NPI:1104174226
Name:ATHLETIC & FAMILY CHIROPRACTIC, PL
Entity type:Organization
Organization Name:ATHLETIC & FAMILY CHIROPRACTIC, PL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FRONT DESK MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-385-5113
Mailing Address - Street 1:2309 WEDNESDAY ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4335
Mailing Address - Country:US
Mailing Address - Phone:850-385-5113
Mailing Address - Fax:850-385-5601
Practice Address - Street 1:2309 WEDNESDAY ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4335
Practice Address - Country:US
Practice Address - Phone:850-385-5113
Practice Address - Fax:850-385-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006369111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty