MEDICARE: CITY OF PALMS CHIROPRACTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH10966	FL

General Provider Information

NPI Number	:	1083039127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF PALMS CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	11621 S CLEVELAND AVE
Second Line	:	UNIT 80
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2866
Country	:	US
Telephone Number	:	239-690-7794
Fax Number	:

Provider Business Practice Location Address
First Line	:	11621 S CLEVELAND AVE
Second Line	:	UNIT 80
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2866
Country	:	US
Telephone Number	:	239-690-7794
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	DR. RYAN SCOTT NICKENS
Credential	:	D.C.
Telephone Number	:	321-615-7998

Provider Enumeration Date	:	02/26/2014
Last Update Date	:	01/16/2015

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