Provider Demographics
NPI:1023075181
Name:MAITLAND CHIROPRACTIC CLINIC INC
Entity type:Organization
Organization Name:MAITLAND CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHRISTIANNE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DUVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-628-9999
Mailing Address - Street 1:500 S MAITLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5622
Mailing Address - Country:US
Mailing Address - Phone:407-628-9999
Mailing Address - Fax:407-628-2917
Practice Address - Street 1:500 S MAITLAND AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5622
Practice Address - Country:US
Practice Address - Phone:407-628-9999
Practice Address - Fax:407-628-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6175111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3817849 00Medicaid
FL74763Medicare ID - Type Unspecified