MEDICARE: MCGOWAN SPINAL REHABILITATION CENTER 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	CH8235	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40249	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1558453662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCGOWAN SPINAL REHABILITATION CENTER PA

Provider Business Mailing Address
First Line	:	PO BOX 17809
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32245-7809
Country	:	US
Telephone Number	:	904-723-0015
Fax Number	:	904-338-0951

Provider Business Practice Location Address
First Line	:	3021 MAIN ST N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-6168
Country	:	US
Telephone Number	:	904-350-5544
Fax Number	:	904-350-9944

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHELITA MCGOWAN
Credential	:	D.C.
Telephone Number	:	904-350-5544

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	07/21/2022

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