Healthcare Provider Details

I. General information

NPI: 1386314482
Provider Name (Legal Business Name): MED QUAD SPINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 CLEVELAND AVE STE 1870
FORT MYERS FL
33901-9064
US

IV. Provider business mailing address

9858 CLINT MOORE RD # C111-274
BOCA RATON FL
33496-1034
US

V. Phone/Fax

Practice location:
  • Phone: 239-400-0956
  • Fax: 239-400-0109
Mailing address:
  • Phone: 561-482-1144
  • Fax: 561-482-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: HOLLY SCHISANI
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 561-482-1144