MEDICARE: CHIROPRACTIC HEALTH CLINIC OF BREVARD PA

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	CH 8328 FL	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K5848	OTHER	FL	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1992995757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC HEALTH CLINIC OF BREVARD PA

Provider Business Mailing Address
First Line	:	110 N TROPICAL TRL
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4737
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 N TROPICAL TRL
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4737
Country	:	US
Telephone Number	:	321-459-9400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL VINCENT GRIMM
Credential	:	D.C.
Telephone Number	:	321-459-9400

Provider Enumeration Date	:	07/27/2007
Last Update Date	:	07/27/2007

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