Healthcare Provider Details

I. General information

NPI: 1447201660
Provider Name (Legal Business Name): SIEVERT CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 COLONIAL BLVD SUITE 1A
FORT MYERS FL
33966-1062
US

IV. Provider business mailing address

3880 COLONIAL BLVD SUITE 1A
FORT MYERS FL
33966-1062
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-1233
  • Fax: 239-936-8576
Mailing address:
  • Phone: 239-936-1233
  • Fax: 239-936-8576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH3599
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS9565
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP2826072
License Number StateFL

VIII. Authorized Official

Name: DR. THOMAS D. SIEVERT
Title or Position: PRESIDENT
Credential: D.C.
Phone: 239-936-1233