Healthcare Provider Details

I. General information

NPI: 1346597960
Provider Name (Legal Business Name): MAITLAND WEST CHIROPRACTIC & LASER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 FENNELL ST SUITE 6
MAITLAND FL
32751-8672
US

IV. Provider business mailing address

1720 FENNELL ST SUITE 6
MAITLAND FL
32751-8672
US

V. Phone/Fax

Practice location:
  • Phone: 321-972-8917
  • Fax: 321-800-3383
Mailing address:
  • Phone: 321-972-8917
  • Fax: 321-800-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberCH9501
License Number StateFL

VIII. Authorized Official

Name: DR. RODEN C STEWART
Title or Position: DOCTOR
Credential: D.C.
Phone: 321-972-8917