=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780952937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THORASSIC PARK, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2011
-----------------------------------------------------
Last Update Date | 12/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1603 60TH AVE W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34207-4658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-758-1402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1603 60TH AVE W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34207-4658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-758-1402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER-PRESIDENT
-----------------------------------------------------
Name | MR. LEO RANGEL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 941-758-1402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NX0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Chiropractor
-----------------------------------------------------
License Number | CH2745
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------