=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104038066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TARTACK CHIROPRACTIC & WELLNESS CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 01/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1222 S ANDREWS AVE SUITE 501
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33316-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-764-4042
-----------------------------------------------------
Fax | 954-764-7275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1222 S ANDREWS AVE SUITE 501
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33316-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-764-4042
-----------------------------------------------------
Fax | 954-764-7275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY S TARTACK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 954-764-4042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH0008769
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------