Provider Demographics
NPI:1396702130
Name:REGIONAL CHIROPRACTIC GROUP PA
Entity type:Organization
Organization Name:REGIONAL CHIROPRACTIC GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WOLFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-649-9699
Mailing Address - Street 1:205 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-1203
Mailing Address - Country:US
Mailing Address - Phone:407-649-9699
Mailing Address - Fax:407-649-8991
Practice Address - Street 1:205 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-1203
Practice Address - Country:US
Practice Address - Phone:407-649-9699
Practice Address - Fax:407-649-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00849Medicare ID - Type Unspecified