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General NPI Number Information
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NPI Number | 1518347061
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Entity Type | Organization
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Legal Business Name | DOCKSIDE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 05/30/2015
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Last Update Date | 05/30/2015
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Provider Practice Location Address
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Address Line | 1300 PINETREE DR STE 7
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City | INDIAN HARBOUR BEACH
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State | FL
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Zip | 32937-4429
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Country | US
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Telephone | 321-775-3734
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 PINETREE DR STE 7
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City | INDIAN HARBOUR BEACH
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State | FL
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Zip | 32937-4429
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Country | US
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Telephone | 321-775-3734
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEVIN CHRISTOPHER POULSTON
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Credential | DC
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Telephone | 678-523-8533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | CH11291
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License Number State | FL
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