Healthcare Provider Details

I. General information

NPI: 1114154457
Provider Name (Legal Business Name): MARK T MACHUGA P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2009
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 BOREN DR STE 300
OCOEE FL
34761-2986
US

IV. Provider business mailing address

1554 BOREN DR STE 300
OCOEE FL
34761-2986
US

V. Phone/Fax

Practice location:
  • Phone: 407-877-9771
  • Fax: 407-877-8505
Mailing address:
  • Phone: 407-877-9771
  • Fax: 407-877-8505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH0004967
License Number StateFL

VIII. Authorized Official

Name: MARK T MACHUGA
Title or Position: PRESIDENT
Credential: D.C.
Phone: 407-877-9771