Healthcare Provider Details

I. General information

NPI: 1679673396
Provider Name (Legal Business Name): PALM COAST CHIROPRACTIC CENTER, JTA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 E MOODY BLVD SUITE 101
BUNNELL FL
32110-7706
US

IV. Provider business mailing address

4721 E MOODY BLVD SUITE 101
BUNNELL FL
32110-7706
US

V. Phone/Fax

Practice location:
  • Phone: 386-437-7111
  • Fax: 386-437-7790
Mailing address:
  • Phone: 386-437-7111
  • Fax: 386-437-7790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8483
License Number StateFL

VIII. Authorized Official

Name: DR. JENNIFER L THORNTON
Title or Position: PRESIDENT
Credential: DC
Phone: 386-437-7111