Healthcare Provider Details

I. General information

NPI: 1639606007
Provider Name (Legal Business Name): RIVERTOWN CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 VICKI TOWERS DR
ST AUGUSTINE FL
32092-1757
US

IV. Provider business mailing address

317 VICKI TOWERS DR
ST AUGUSTINE FL
32092-1757
US

V. Phone/Fax

Practice location:
  • Phone: 904-428-0766
  • Fax:
Mailing address:
  • Phone: 904-428-0766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number11946
License Number StateFL

VIII. Authorized Official

Name: DR. PHILIP GREGORY RODGER
Title or Position: CO-OWNER/CHIROPRACTOR
Credential: DC
Phone: 904-428-0766