Healthcare Provider Details

I. General information

NPI: 1114401544
Provider Name (Legal Business Name): CHIRO & LASER PAIN RELIEF CENTER OF ST AUGUSTINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 S PONCE DE LEON BLVD STE K
ST AUGUSTINE FL
32084-6018
US

IV. Provider business mailing address

1092 S PONCE DE LEON BLVD STE K
ST AUGUSTINE FL
32084-6018
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-2923
  • Fax:
Mailing address:
  • Phone: 904-460-2923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: GARY TRUPO
Title or Position: DOCTOR
Credential: DC
Phone: 904-460-2923