Healthcare Provider Details

I. General information

NPI: 1104282615
Provider Name (Legal Business Name): RADIUSTBI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 N DIXIE HWY
OAKLAND PARK FL
33334-3928
US

IV. Provider business mailing address

4805 N DIXIE HWY
OAKLAND PARK FL
33334-3928
US

V. Phone/Fax

Practice location:
  • Phone: 954-598-0779
  • 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 Code111NN0400X
TaxonomyNeurology Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN MEVORAH
Title or Position: CHIROPRACTIC PHYSICAN
Credential: D.C
Phone: 954-471-2133