Healthcare Provider Details

I. General information

NPI: 1467652578
Provider Name (Legal Business Name): COLUMBIA COUNTY CHIROPRACTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 SW MAIN BLVD
LAKE CITY FL
32025-7050
US

IV. Provider business mailing address

279 SW MAIN BLVD
LAKE CITY FL
32025-7050
US

V. Phone/Fax

Practice location:
  • Phone: 386-752-4313
  • Fax: 386-752-8356
Mailing address:
  • Phone: 386-752-4313
  • Fax: 386-752-8356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCH5141
License Number StateFL

VIII. Authorized Official

Name: DR. DARREL THOMAS MATHIS
Title or Position: OWNER/PHYSICIAN
Credential: D.C.
Phone: 386-752-4313