Healthcare Provider Details

I. General information

NPI: 1134249618
Provider Name (Legal Business Name): COMPLETE WELLNESS CHIROPRACTIC CENTER OF DELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 N STONE ST SUIT 202
DELAND FL
32720-3208
US

IV. Provider business mailing address

844 N STONE ST SUIT 202
DELAND FL
32720-3208
US

V. Phone/Fax

Practice location:
  • Phone: 386-734-2592
  • Fax: 386-734-1773
Mailing address:
  • Phone: 386-734-2592
  • Fax: 386-734-1773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA36547
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT16948
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8909
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH10693
License Number State
# 5
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCH4523
License Number StateFL

VIII. Authorized Official

Name: J RANDALL TIMKO
Title or Position: OWNER
Credential:
Phone: 386-734-2592