Provider Demographics
NPI:1336933399
Name:WAVE SPORTS CHIROPRACTIC LLC
Entity type:Organization
Organization Name:WAVE SPORTS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:E
Authorized Official - Last Name:CORNIER BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:470-899-9800
Mailing Address - Street 1:1509 AVE PONCE DE LEON APT 1181
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909-1797
Mailing Address - Country:US
Mailing Address - Phone:470-899-9800
Mailing Address - Fax:
Practice Address - Street 1:G3 CALLE ONEILL STE 3
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-2361
Practice Address - Country:US
Practice Address - Phone:787-909-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty