Healthcare Provider Details

I. General information

NPI: 1184903064
Provider Name (Legal Business Name): CHIROPRACTIC SPINE AND INJURY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 BLANDING BLVD STE 106
ORANGE PARK FL
32065-7724
US

IV. Provider business mailing address

784 BLANDING BLVD STE 106
ORANGE PARK FL
32065-7724
US

V. Phone/Fax

Practice location:
  • Phone: 904-276-7002
  • Fax: 904-272-0086
Mailing address:
  • Phone: 904-276-7002
  • Fax: 904-272-0086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES W. DAUTEL
Title or Position: PRESIDENT/CFO
Credential: D.C.
Phone: 904-276-7002