Provider Demographics
NPI:1538437272
Name:BAYBRIDGE CHIROPRACTIC CLINIC, P.A.
Entity type:Organization
Organization Name:BAYBRIDGE CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEAMON
Authorized Official - Last Name:WILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-932-1778
Mailing Address - Street 1:107 BAYBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4470
Mailing Address - Country:US
Mailing Address - Phone:850-932-1778
Mailing Address - Fax:850-934-4770
Practice Address - Street 1:107 BAY BRIDGE DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7428
Practice Address - Country:US
Practice Address - Phone:850-932-1778
Practice Address - Fax:850-934-4770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH00005184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT94462Medicare UPIN