Provider Demographics
NPI:1538551403
Name:RETREAT CHIROPRACTIC & WELLNESS LLC
Entity type:Organization
Organization Name:RETREAT CHIROPRACTIC & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-551-5631
Mailing Address - Street 1:2608 NE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4319
Mailing Address - Country:US
Mailing Address - Phone:954-551-5631
Mailing Address - Fax:
Practice Address - Street 1:2608 NE 16TH AVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33334-4319
Practice Address - Country:US
Practice Address - Phone:954-551-5631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11161111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty