Provider Demographics
NPI:1902265705
Name:SAGE CHIROPRACTIC WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:SAGE CHIROPRACTIC WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:KALA
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-829-3348
Mailing Address - Street 1:69 S DIXIE HWY
Mailing Address - Street 2:SUITE C1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-4186
Mailing Address - Country:US
Mailing Address - Phone:904-829-3348
Mailing Address - Fax:904-829-3348
Practice Address - Street 1:69 S DIXIE HWY
Practice Address - Street 2:SUITE C1
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4186
Practice Address - Country:US
Practice Address - Phone:904-829-3348
Practice Address - Fax:904-829-3348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH006632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty