=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962726703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOEL A TATE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2010
-----------------------------------------------------
Last Update Date | 03/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 S MAIN ST
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-4250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-362-6767
-----------------------------------------------------
Fax | 850-362-6867
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 S MAIN ST
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536
-----------------------------------------------------
Country | UM
-----------------------------------------------------
Telephone | 850-398-8640
-----------------------------------------------------
Fax | 850-398-8641
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9929
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------