Provider Demographics
NPI:1588720106
Name:BLUE ANGEL FAMILY CHIROPRACTIC PA
Entity type:Organization
Organization Name:BLUE ANGEL FAMILY CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:FONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-453-2211
Mailing Address - Street 1:5700 N BLUE ANGEL PKWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-1620
Mailing Address - Country:US
Mailing Address - Phone:850-453-2211
Mailing Address - Fax:850-453-3366
Practice Address - Street 1:5700 N BLUE ANGEL PKWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-1620
Practice Address - Country:US
Practice Address - Phone:850-453-2211
Practice Address - Fax:850-453-3366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74785OtherBLUE CROSS GROUP NUMBER
FLK2276Medicare PIN