Healthcare Provider Details

I. General information

NPI: 1255513602
Provider Name (Legal Business Name): ADVANCED CHIROPRACTIC REHABILITATION AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15151 S US HIGHWAY 441
SUMMERFIELD FL
34491-4481
US

IV. Provider business mailing address

15151 S US HIGHWAY 441 SUITE 200
SUMMERFIELD FL
34491-4481
US

V. Phone/Fax

Practice location:
  • Phone: 352-307-0033
  • Fax: 352-307-1998
Mailing address:
  • Phone: 352-307-0033
  • Fax: 352-307-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH2831
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberCH2831
License Number StateNY

VIII. Authorized Official

Name: DR. THOMAS FRANK MAMMANA
Title or Position: OWNER
Credential: CHIROPRACTOR
Phone: 352-307-0033