Provider Demographics
NPI:1992995757
Name:CHIROPRACTIC HEALTH CLINIC OF BREVARD PA
Entity type:Organization
Organization Name:CHIROPRACTIC HEALTH CLINIC OF BREVARD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-459-9400
Mailing Address - Street 1:110 N TROPICAL TRL
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 N TROPICAL TRL
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4737
Practice Address - Country:US
Practice Address - Phone:321-459-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8328 FL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5848OtherMEDICARE GROUP NUMBER
FLK5848OtherMEDICARE GROUP NUMBER
FLV00179 FLMedicare UPIN