Provider Demographics
NPI:1720171721
Name:DEJESUS CHIROPRACTIC CENTER PA
Entity type:Organization
Organization Name:DEJESUS CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEJESUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:305-661-4989
Mailing Address - Street 1:7520 S RED RD STE F
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5330
Mailing Address - Country:US
Mailing Address - Phone:305-661-4989
Mailing Address - Fax:303-374-0081
Practice Address - Street 1:7520 S RED RD STE F
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-5330
Practice Address - Country:US
Practice Address - Phone:305-661-4989
Practice Address - Fax:305-374-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005249111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39619OtherBLUE CROSS BLUE SHIELD GR
FL050688500Medicaid
FLT87697Medicare UPIN