MEDICARE: OVIEDO CHIROPRACTIC LLC

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	:	1700286697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OVIEDO CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	2871 CLAYTON CROSSING WAY
Second Line	:	SUITE 1073
City	:	OVIEDO
State	:	FL
Zip	:	32765-3426
Country	:	US
Telephone Number	:	407-542-1614
Fax Number	:

Provider Business Practice Location Address
First Line	:	2871 CLAYTON CROSSING WAY
Second Line	:	SUITE 1073
City	:	OVIEDO
State	:	FL
Zip	:	32765-3426
Country	:	US
Telephone Number	:	407-542-1614
Fax Number	:	407-542-1615

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JUSTIN COUGH
Credential	:
Telephone Number	:	407-542-1614

Provider Enumeration Date	:	08/27/2014
Last Update Date	:	03/25/2015

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