Provider Demographics
NPI:1053725747
Name:KISSIMMEE INJURY CLINIC LLC
Entity type:Organization
Organization Name:KISSIMMEE INJURY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DC
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNAID
Authorized Official - Middle Name:Q
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-280-5052
Mailing Address - Street 1:280 S STATE ROAD 434 STE 1049A
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3859
Mailing Address - Country:US
Mailing Address - Phone:321-280-5052
Mailing Address - Fax:
Practice Address - Street 1:512 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4114
Practice Address - Country:US
Practice Address - Phone:321-280-5052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10638111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty