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General NPI Number Information
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NPI Number | 1194079087
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Entity Type | Organization
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Legal Business Name | EAST COAST CHIROPRACTIC
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Dates
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Enumeration Date | 10/31/2012
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Last Update Date | 10/31/2012
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Provider Practice Location Address
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Address Line | 3729 S NOVA RD
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City | PORT ORANGE
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State | FL
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Zip | 32129-4233
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Country | US
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Telephone | 386-761-0520
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Fax |
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Provider Business Mailing Address
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Address Line | 2545 S ATLANTIC AVE APT 207
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City | DAYTONA BEACH SHORES
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State | FL
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Zip | 32118-5539
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Country | US
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Telephone | 386-761-0520
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Fax |
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. LESLIE PELLETIER
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Credential | DC
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Telephone | 386-761-0520
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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 | CH10769
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License Number State | FL
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