Provider Demographics
NPI:1538359187
Name:BUSH CHIROPRACTIC CLINIC PA
Entity type:Organization
Organization Name:BUSH CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-965-2999
Mailing Address - Street 1:2402 LAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-5008
Mailing Address - Country:US
Mailing Address - Phone:863-965-2999
Mailing Address - Fax:863-965-2990
Practice Address - Street 1:2402 LAKE DR NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-5008
Practice Address - Country:US
Practice Address - Phone:863-965-2999
Practice Address - Fax:863-965-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP039AMedicare PIN