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General NPI Number Information
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NPI Number | 1730629528
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 02/28/2017
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Last Update Date | 02/28/2017
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Provider Practice Location Address
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Address Line | 145 HILDEN RD SUITE 123
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City | PONTE VEDRA
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State | FL
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Zip | 32081-8401
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Country | US
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Telephone | 904-395-5371
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Fax |
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Provider Business Mailing Address
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Address Line | 145 HILDEN RD SUITE 123
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City | PONTE VEDRA
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State | FL
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Zip | 32081-8401
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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 | OWNER
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Name | ADAM PODRAZA
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Credential |
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Telephone | 904-395-5371
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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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