=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124341995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIALKOV CHIROPRACTIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2010
-----------------------------------------------------
Last Update Date | 01/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 279 S YONGE ST
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-6257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-334-3362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 S YONGE ST
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-6257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-334-3362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | ROSS A FIALKOV
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 386-334-3362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9759
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------