MEDICARE: BUSH CHIROPRACTIC CLINIC PA

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

General Provider Information

NPI Number	:	1538359187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUSH CHIROPRACTIC CLINIC PA

Provider Business Mailing Address
First Line	:	2402 LAKE DR NW
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-5008
Country	:	US
Telephone Number	:	863-965-2999
Fax Number	:	863-965-2990

Provider Business Practice Location Address
First Line	:	2402 LAKE DR NW
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-5008
Country	:	US
Telephone Number	:	863-965-2999
Fax Number	:	863-965-2990

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARY W. BUSH
Credential	:	D.C.
Telephone Number	:	863-965-2999

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	11/18/2009

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