=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124301577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STALNAKER WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2011
-----------------------------------------------------
Last Update Date | 09/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1127 HIDDEN COVE CIR S
-----------------------------------------------------
City | ATLANTIC BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32233-6915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-502-9437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1127 HIDDEN COVE CIR S
-----------------------------------------------------
City | ATLANTIC BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32233-6915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-502-9437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | DR. ZACHARY WINFIED STALNAKER
-----------------------------------------------------
Credential | D.C., B.S.B.A
-----------------------------------------------------
Telephone | 850-502-9437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9924
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------