Healthcare Provider Details

I. General information

NPI: 1487311874
Provider Name (Legal Business Name): RUSTY LAVENDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5899 WHITFIELD AVE STE 107
SARASOTA FL
34243-3127
US

IV. Provider business mailing address

5899 WHITFIELD AVE STE 107
SARASOTA FL
34243-3127
US

V. Phone/Fax

Practice location:
  • Phone: 941-243-3729
  • Fax:
Mailing address:
  • Phone: 941-243-3729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH13802
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: