Provider Demographics
NPI:1053730218
Name:PROGRESSIVE CHIROPRACTIC AND REHABILITATION
Entity type:Organization
Organization Name:PROGRESSIVE CHIROPRACTIC AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-830-9694
Mailing Address - Street 1:502 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-4250
Mailing Address - Country:US
Mailing Address - Phone:850-398-8640
Mailing Address - Fax:850-398-8641
Practice Address - Street 1:502 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-4250
Practice Address - Country:US
Practice Address - Phone:850-398-8640
Practice Address - Fax:850-398-8641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9929111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH9929OtherMEDICAL LICENSE
FL220C0OtherBLUE CROSS BLUE SHIELD PROVIDER NUMBER