Healthcare Provider Details

I. General information

NPI: 1174534218
Provider Name (Legal Business Name): MITCHELL ANTHONY WOMACK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 01/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 PALM BAY RD NE SUITE C
PALM BAY FL
32905-3829
US

IV. Provider business mailing address

1430 PALM BAY RD NE SUITE C
PALM BAY FL
32905-3829
US

V. Phone/Fax

Practice location:
  • Phone: 321-723-2113
  • Fax: 321-952-0848
Mailing address:
  • Phone: 321-723-2113
  • Fax: 321-952-0848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCH0005440
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: