Provider Demographics
NPI:1669587259
Name:CLINICAL CHIROPRACTIC GROUP, INC.
Entity type:Organization
Organization Name:CLINICAL CHIROPRACTIC GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:754-701-5194
Mailing Address - Street 1:6918 CYPRESS RD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2318
Mailing Address - Country:US
Mailing Address - Phone:954-701-5194
Mailing Address - Fax:954-701-5191
Practice Address - Street 1:6918 CYPRESS RD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2318
Practice Address - Country:US
Practice Address - Phone:954-701-5194
Practice Address - Fax:954-701-5191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7805111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL382046700Medicaid
FLQ0187Medicare PIN
FL5962880001Medicare NSC