Healthcare Provider Details

I. General information

NPI: 1720497340
Provider Name (Legal Business Name): HAVLICEK CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 A1A S STE 103
ST AUGUSTINE FL
32080-6505
US

IV. Provider business mailing address

2085 A1A S STE 103
ST AUGUSTINE FL
32080-6505
US

V. Phone/Fax

Practice location:
  • Phone: 904-522-2515
  • Fax: 904-515-2235
Mailing address:
  • Phone: 904-515-2225
  • Fax: 904-515-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRADLEY HAVLICEK
Title or Position: PRESIDENT
Credential: D.C.
Phone: 904-515-2225