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General NPI Number Information
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NPI Number | 1356090245
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Entity Type | Organization
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Legal Business Name | PORT CHARLOTTE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 03/20/2022
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Last Update Date | 04/14/2022
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Provider Practice Location Address
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Address Line | 795 CRESTVIEW CIR NW
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City | PORT CHARLOTTE
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State | FL
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Zip | 33948-2126
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Country | US
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Telephone | 941-629-8444
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Fax |
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Provider Business Mailing Address
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Address Line | 795 CRESTVIEW CIR NW
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City | PORT CHARLOTTE
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State | FL
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Zip | 33948-2126
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. LAWRENCE C WALLEN III
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Credential | DC
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Telephone | 815-252-9783
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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 |
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License Number State |
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