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General NPI Number Information
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NPI Number | 1467737130
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Entity Type | Organization
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Legal Business Name | HEATHROW FAMILY CHIROPRACTIC
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Dates
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Enumeration Date | 10/13/2011
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Last Update Date | 10/13/2011
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Provider Practice Location Address
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Address Line | 1130 TOWNPARK AVE SUITE 1116
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City | LAKE MARY
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State | FL
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Zip | 32746-4787
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Country | US
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Telephone | 407-756-6998
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 CHERRY LAKE WAY
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City | LAKE MARY
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State | FL
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Zip | 32746-1962
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Country | US
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Telephone | 407-756-6998
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | DR. KELLY TOLLE
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Credential | D.C.
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Telephone | 407-756-6998
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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 | CH10438
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License Number State | FL
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