Healthcare Provider Details

I. General information

NPI: 1922370246
Provider Name (Legal Business Name): PREMIER HEALTH ORMOND, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 CLYDE MORRIS BLVD SUITE #390
ORMOND BEACH FL
32174-8178
US

IV. Provider business mailing address

325 CLYDE MORRIS BLVD SUITE #390
ORMOND BEACH FL
32174-8178
US

V. Phone/Fax

Practice location:
  • Phone: 386-872-3600
  • Fax: 386-615-9137
Mailing address:
  • Phone: 386-872-3600
  • Fax: 386-615-9137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH10080
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number057503
License Number StateFL

VIII. Authorized Official

Name: DR. CHRISTOPHER BURNHAM
Title or Position: CHIROPRACTIC SERVICES DIRECTOR
Credential: D.C.
Phone: 386-872-3600