MEDICARE: EAST LAKE CHIROPRACTIC & MEDICAL CENTER, 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1811495617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST LAKE CHIROPRACTIC & MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	4028 13TH ST
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-6773
Country	:	US
Telephone Number	:	407-957-9995
Fax Number	:	407-957-7536

Provider Business Practice Location Address
First Line	:	4028 13TH ST
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-6773
Country	:	US
Telephone Number	:	407-957-9995
Fax Number	:	407-957-7536

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHRISTOPHER MCNICHOLS
Credential	:	DC
Telephone Number	:	407-957-9995

Provider Enumeration Date	:	01/26/2018
Last Update Date	:	03/17/2018

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