Provider Demographics
NPI:1780944462
Name:TANNER MARTINEZ CHIROPRACTIC LLC
Entity type:Organization
Organization Name:TANNER MARTINEZ CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-819-9110
Mailing Address - Street 1:2200 N PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2600
Mailing Address - Country:US
Mailing Address - Phone:904-819-9110
Mailing Address - Fax:904-819-9310
Practice Address - Street 1:2200 N PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2600
Practice Address - Country:US
Practice Address - Phone:904-819-9110
Practice Address - Fax:904-819-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10578111NI0013X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ300052763DMedicare UPIN