MEDICARE: MATRIX SPINE AND SPORTS MEDICINE, 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	111NX0800X	Orthopedic Chiropractor

General Provider Information

NPI Number	:	1134846066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATRIX SPINE AND SPORTS MEDICINE, LLC

Provider Business Mailing Address
First Line	:	43 S POWERLINE RD STE 245
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33069-3001
Country	:	US
Telephone Number	:	954-228-8486
Fax Number	:	954-228-2601

Provider Business Practice Location Address
First Line	:	150 SW 12TH AVE STE 440
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33069-3200
Country	:	US
Telephone Number	:	954-228-8486
Fax Number	:	954-228-2601

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	DR. DENNIS BONNEAU
Credential	:	CH
Telephone Number	:	954-228-8486

Provider Enumeration Date	:	10/21/2022
Last Update Date	:	10/21/2022

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