Provider Demographics
NPI:1992421002
Name:DISC CENTER OF PORT ST LUCIE LLC
Entity type:Organization
Organization Name:DISC CENTER OF PORT ST LUCIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRASSAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-237-2080
Mailing Address - Street 1:555 NW LAKE WHITNEY PL STE 105
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 NW LAKE WHITNEY PL STE 105
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1623
Practice Address - Country:US
Practice Address - Phone:772-237-2080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty