MEDICARE: JAMES C HERNDON JR DC P A

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	CH 5763	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22198	OTHER	FL	BCBS PROVIDER ID NUMBER

General Provider Information

NPI Number	:	1376968412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAMES C HERNDON JR DC P A

Provider Business Mailing Address
First Line	:	7575 DR PHILLIPS BLVD STE 110
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-7221
Country	:	US
Telephone Number	:	407-345-0508
Fax Number	:	407-345-0509

Provider Business Practice Location Address
First Line	:	7575 DR PHILLIPS BLVD STE 110
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-7221
Country	:	US
Telephone Number	:	407-345-0508
Fax Number	:	407-345-0509

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES C. HERNDON JR.
Credential	:	D.C.
Telephone Number	:	407-345-0508

Provider Enumeration Date	:	02/26/2014
Last Update Date	:	11/23/2015

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