Provider Demographics
NPI:1992572986
Name:CHIROPRACTIC SPORT AND FAMILY WELLNESS LLC
Entity type:Organization
Organization Name:CHIROPRACTIC SPORT AND FAMILY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RICHARDSON-SICRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:571-220-1362
Mailing Address - Street 1:13224 SR 64
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-9403
Mailing Address - Country:US
Mailing Address - Phone:941-777-2739
Mailing Address - Fax:
Practice Address - Street 1:13224 SR 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212-9403
Practice Address - Country:US
Practice Address - Phone:941-777-2739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty