MEDICARE: FUNCTIONAL SPINE CHIROPRACTIC & REHAB 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	111NR0400X	Rehabilitation Chiropractor
2	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1205792405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL SPINE CHIROPRACTIC & REHAB LLC

Provider Business Mailing Address
First Line	:	7825 N DALE MABRY HWY STE 104
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-3207
Country	:	US
Telephone Number	:	813-709-8363
Fax Number	:

Provider Business Practice Location Address
First Line	:	7825 N DALE MABRY HWY STE 104
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-3207
Country	:	US
Telephone Number	:	813-709-8363
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VICTOR MATIAS
Credential	:	DC
Telephone Number	:	813-709-8363

Provider Enumeration Date	:	12/31/2025
Last Update Date	:	12/31/2025

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