Provider Demographics
NPI:1700666047
Name:SPINE OF LIFE UPPER CERVICAL CHIROPRACTIC
Entity type:Organization
Organization Name:SPINE OF LIFE UPPER CERVICAL CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PECCA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-740-0007
Mailing Address - Street 1:2225 A1A S STE A1
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6374
Mailing Address - Country:US
Mailing Address - Phone:732-740-0007
Mailing Address - Fax:
Practice Address - Street 1:2225 A1A S STE A1
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6374
Practice Address - Country:US
Practice Address - Phone:732-740-0007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty