Provider Demographics
NPI:1144460726
Name:FULL BLOOM CHIROPRACTIC CORP
Entity type:Organization
Organization Name:FULL BLOOM CHIROPRACTIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-481-8552
Mailing Address - Street 1:115 LAND GRANT ST STE 3
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3845
Mailing Address - Country:US
Mailing Address - Phone:904-481-8552
Mailing Address - Fax:
Practice Address - Street 1:115 LAND GRANT ST STE 3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3845
Practice Address - Country:US
Practice Address - Phone:904-481-8552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty