MEDICARE: COLONIAL CHIROPRACTIC CENTER

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	:	1558540260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL CHIROPRACTIC CENTER

Provider Business Mailing Address
First Line	:	1310 W COLONIAL DR STE 21-23
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-7139
Country	:	US
Telephone Number	:	407-849-0444
Fax Number	:	407-841-0037

Provider Business Practice Location Address
First Line	:	1310 W COLONIAL DR STE 21-23
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-7139
Country	:	US
Telephone Number	:	407-849-0444
Fax Number	:	407-841-0037

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SHONA SHERINIKA JOHNSON
Credential	:
Telephone Number	:	321-615-8977

Provider Enumeration Date	:	10/30/2007
Last Update Date	:	10/30/2007

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