Provider Demographics
NPI:1316936206
Name:BOLICK, CHANNING C (MS, DC)
Entity type:Individual
Prefix:DR
First Name:CHANNING
Middle Name:C
Last Name:BOLICK
Suffix:
Gender:M
Credentials:MS, DC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 E HORATIO AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7310
Mailing Address - Country:US
Mailing Address - Phone:407-629-5333
Mailing Address - Fax:407-629-5343
Practice Address - Street 1:500 E HORATIO AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7310
Practice Address - Country:US
Practice Address - Phone:407-629-5333
Practice Address - Fax:407-629-5343
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7882111N00000X
SC2398111N00000X
GA6191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH7882OtherSTATE LICENSE NUMBER
FL2800039-00Medicaid
FL350050297OtherRAILROAD MEDICARE
FL4573235OtherGHI PROVIDER NUMBER
FL1455405OtherCIGNA PROVIDER NUMBER
FL53988OtherASHLINK PIN
FL55996OtherBLUE CROSS NUMBER
FL945833OtherPPNI PROVIDER NUMBER
FLK1903OtherMEDICARE GROUP NUMBER
FLP10000175970OtherSUNSHINE STATE
10728811OtherCAQH NUMBER
FL332352OtherAVMED PROVIDER NUMBER
544703OtherWELLCARE/STAYWELL MEDICARE & MEDICAID
FLK1903OtherMEDICARE GROUP NUMBER
FLU74151Medicare UPIN