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General NPI Number Information
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NPI Number | 1003081290
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Entity Type | Organization
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Legal Business Name | LAKE WALES CHIROPRACTIC CENTER INC
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Dates
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Enumeration Date | 04/28/2008
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Last Update Date | 04/28/2008
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Provider Practice Location Address
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Address Line | 343 W CENTRAL AVE SUITE 103
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City | LAKE WALES
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State | FL
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Zip | 33853-4059
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Country | US
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Telephone | 863-676-7619
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Fax | 863-676-7610
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Provider Business Mailing Address
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Address Line | 343 W CENTRAL AVE SUITE 103
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City | LAKE WALES
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State | FL
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Zip | 33853-4059
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Country | US
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Telephone | 863-676-7619
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Fax | 863-676-7610
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RONALD L. HARRELL
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Credential | DC
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Telephone | 863-676-7619
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH4000
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License Number State | FL
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