Provider Demographics
NPI:1316279565
Name:ENDEAVOR CHIROPRACTIC LLC
Entity type:Organization
Organization Name:ENDEAVOR CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOSTAPH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-326-5551
Mailing Address - Street 1:6053 SPINNAKER LOOP
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-5922
Mailing Address - Country:US
Mailing Address - Phone:352-326-5551
Mailing Address - Fax:
Practice Address - Street 1:26540 ACE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8279
Practice Address - Country:US
Practice Address - Phone:352-326-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty