Healthcare Provider Details

I. General information

NPI: 1609241884
Provider Name (Legal Business Name): HEAVENLY TOUCH CHIROPRACTIC REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 LAKE MIRIAM DR SUITE W-3
LAKELAND FL
33813-2180
US

IV. Provider business mailing address

202 LAKE MIRIAM DR SUITE W-3
LAKELAND FL
33813-2180
US

V. Phone/Fax

Practice location:
  • Phone: 863-647-0808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: KOTEUAISA WILSON
Title or Position: MANAGER
Credential:
Phone: 863-647-0808