Healthcare Provider Details

I. General information

NPI: 1780006403
Provider Name (Legal Business Name): PURE CHIROPRACTIC & NATURAL HEALTH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WAYMONT CT SUITE 126, UNIT #3
LAKE MARY FL
32746-3413
US

IV. Provider business mailing address

200 WAYMONT CT SUITE 126, UNIT #3
LAKE MARY FL
32746-3413
US

V. Phone/Fax

Practice location:
  • Phone: 407-682-4454
  • Fax: 407-682-3805
Mailing address:
  • Phone: 407-682-4454
  • Fax: 407-682-3805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberCH3063
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberCH3063
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCH3063
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH3063
License Number StateFL

VIII. Authorized Official

Name: DR. NEAL WIEDER
Title or Position: PRESIDENT
Credential:
Phone: 407-682-4454