MEDICARE: SOUTHWEST SPINE AND SPORT, INC.

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		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70007	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1316153661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST SPINE AND SPORT, INC.

Provider Business Mailing Address
First Line	:	1722 DEL PRADO BLVD S STE 4
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-5522
Country	:	US
Telephone Number	:	239-772-8888
Fax Number	:

Provider Business Practice Location Address
First Line	:	1722 DEL PRADO BLVD S STE 4
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-5522
Country	:	US
Telephone Number	:	239-772-8888
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEITH Q WARDE
Credential	:	DC
Telephone Number	:	239-772-8888

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	08/22/2020

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Directions to “SOUTHWEST SPINE AND SPORT, INC. ” Practice Location

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