Provider Demographics
NPI:1265594170
Name:HEALTHY LIVING CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:HEALTHY LIVING CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:A HOLLEY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:RALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-682-3352
Mailing Address - Street 1:924 N FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1706
Mailing Address - Country:US
Mailing Address - Phone:850-682-3352
Mailing Address - Fax:850-682-3352
Practice Address - Street 1:924 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-1706
Practice Address - Country:US
Practice Address - Phone:850-682-3352
Practice Address - Fax:850-682-3352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2873Medicare ID - Type UnspecifiedMEDICARE GROUP #