MEDICARE: BEACHTOWN CHIROPRACTIC CO., 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	CH12515	FL

General Provider Information

NPI Number	:	1336625532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHTOWN CHIROPRACTIC CO., LLC

Provider Business Mailing Address
First Line	:	323 AIRPORT RD STE C
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-5701
Country	:	US
Telephone Number	:	334-212-0101
Fax Number	:

Provider Business Practice Location Address
First Line	:	15600 PANAMA CITY BEACH PKWY UNIT 700
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-5430
Country	:	US
Telephone Number	:	334-790-0484
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR OF CHIROPRACTIC
Name	:	JEFFREY TYLER GREGORY
Credential	:	DC
Telephone Number	:	334-790-0484

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	10/24/2018

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