Provider Demographics
NPI:1174534218
Name:WOMACK, MITCHELL ANTHONY (DC)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ANTHONY
Last Name:WOMACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 PALM BAY RD NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3829
Mailing Address - Country:US
Mailing Address - Phone:321-723-2113
Mailing Address - Fax:321-952-0848
Practice Address - Street 1:1430 PALM BAY RD NE
Practice Address - Street 2:SUITE C
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-3829
Practice Address - Country:US
Practice Address - Phone:321-723-2113
Practice Address - Fax:321-952-0848
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005440111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380015600Medicaid
FL70957ZMedicare PIN
U21704Medicare UPIN
FL380015600Medicaid