MEDICARE: PONTE VEDRA BEACH CHIROPRACTIC INC

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	11715	FL

General Provider Information

NPI Number	:	1598287146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONTE VEDRA BEACH CHIROPRACTIC INC

Provider Business Mailing Address
First Line	:	240 PONTE VEDRA PARK DR STE 150
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-6612
Country	:	US
Telephone Number	:	904-285-2243
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 PONTE VEDRA PARK DR STE 150
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-6612
Country	:	US
Telephone Number	:	904-285-2243
Fax Number	:

Authorized Official
Title or Position	:	PRES
Name	:	CLIFF DANIEL HILL
Credential	:	DC
Telephone Number	:	904-285-2243

Provider Enumeration Date	:	07/14/2017
Last Update Date	:	07/21/2022

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