Healthcare Provider Details

I. General information

NPI: 1700666047
Provider Name (Legal Business Name): SPINE OF LIFE UPPER CERVICAL CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 A1A S STE A1
ST AUGUSTINE FL
32080-6374
US

IV. Provider business mailing address

2225 A1A S STE A1
ST AUGUSTINE FL
32080-6374
US

V. Phone/Fax

Practice location:
  • Phone: 732-740-0007
  • Fax:
Mailing address:
  • Phone: 732-740-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KEVIN PECCA
Title or Position: OWNER
Credential: DC
Phone: 732-740-0007