Provider Demographics
NPI:1386746428
Name:DEINER, JOHN BRADLEY (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:DEINER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 VIRGINIA AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5881
Mailing Address - Country:US
Mailing Address - Phone:772-460-9000
Mailing Address - Fax:772-460-6697
Practice Address - Street 1:805 VIRGINIA AVE STE 10
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5881
Practice Address - Country:US
Practice Address - Phone:772-460-9000
Practice Address - Fax:772-460-6697
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88309AMedicare ID - Type Unspecified