Provider Demographics
NPI:1902983166
Name:PIERCE CHIROPRACTIC & REHABILITATION PA
Entity Type:Organization
Organization Name:PIERCE CHIROPRACTIC & REHABILITATION PA
Other - Org Name:FORMERLY-FORME MEDICAL AND REHABILITATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:A
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:904-724-5433
Mailing Address - Street 1:8773 PERIMETER PARK CT.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE,
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1165
Mailing Address - Country:US
Mailing Address - Phone:904-724-5433
Mailing Address - Fax:904-724-9671
Practice Address - Street 1:8773 PERIMETER PARK CT.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE,
Practice Address - State:FL
Practice Address - Zip Code:32216-1165
Practice Address - Country:US
Practice Address - Phone:904-724-5433
Practice Address - Fax:904-724-9671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
FLCH1273111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38365OtherBCBS
FLCJ4021Medicare PIN
FLCJ4021Medicare PIN