Healthcare Provider Details

I. General information

NPI: 1285640136
Provider Name (Legal Business Name): RONALD L HARRELL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 W CENTRAL AVE SUITE 3
LAKE WALES FL
33853-4059
US

IV. Provider business mailing address

343 W CENTRAL AVE SUITE 3
LAKE WALES FL
33853-4059
US

V. Phone/Fax

Practice location:
  • Phone: 863-676-7619
  • Fax: 863-676-7610
Mailing address:
  • Phone: 863-676-7619
  • Fax: 863-676-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH4000
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: