MEDICARE: PRISM CHIROPRACTIC AND WELLNESS CENTER, L.L.C.

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	111NS0005X	Sports Physician Chiropractor

General Provider Information

NPI Number	:	1881437978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISM CHIROPRACTIC AND WELLNESS CENTER, L.L.C.

Provider Business Mailing Address
First Line	:	2250 SW 71ST TER
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33317-7136
Country	:	US
Telephone Number	:	305-450-7739
Fax Number	:

Provider Business Practice Location Address
First Line	:	2250 SW 71ST TER
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33317-7136
Country	:	US
Telephone Number	:	305-450-7739
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/ CEO
Name	:	DR. PARKER CLIVE DOMINIQUE
Credential	:	DC
Telephone Number	:	305-450-7739

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	06/17/2024

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