Healthcare Provider Details

I. General information

NPI: 1891991386
Provider Name (Legal Business Name): DECOMPRESSION AND SPINAL REHAB OF SWFL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16517 VANDERBILT DR SUITE 1
BONITA SPRINGS FL
34134-7550
US

IV. Provider business mailing address

16517 VANDERBILT DR SUITE 1
BONITA SPRINGS FL
34134-7550
US

V. Phone/Fax

Practice location:
  • Phone: 239-947-7844
  • Fax: 239-947-6338
Mailing address:
  • Phone: 239-947-7844
  • Fax: 239-947-6338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6185490001
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH7598
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4617
License Number StateFL

VIII. Authorized Official

Name: DR. DAN BARTLEY
Title or Position: CLINIC DIRECTOR
Credential: D.C.
Phone: 239-947-7844