Healthcare Provider Details

I. General information

NPI: 1962952531
Provider Name (Legal Business Name): CREATIVE CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 W 49TH ST STE 1104
HIALEAH FL
33012-2995
US

IV. Provider business mailing address

1685 W 49TH ST STE 1104
HIALEAH FL
33012-2995
US

V. Phone/Fax

Practice location:
  • Phone: 954-364-6270
  • Fax: 954-252-2132
Mailing address:
  • Phone: 954-364-6270
  • Fax: 954-252-2132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DAVID D GACKSTETTER
Title or Position: OWNER
Credential: DC
Phone: 954-364-6270