Healthcare Provider Details

I. General information

NPI: 1093769788
Provider Name (Legal Business Name): LARISSA NICOLE TENZYCKI D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 N JOHN SIMS PKWY STE B
VALPARAISO FL
32580-1005
US

IV. Provider business mailing address

127 N JOHN SIMS PKWY STE B
VALPARAISO FL
32580-1005
US

V. Phone/Fax

Practice location:
  • Phone: 850-696-0363
  • Fax:
Mailing address:
  • Phone: 850-696-0363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH 8824
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: