Healthcare Provider Details

I. General information

NPI: 1598820821
Provider Name (Legal Business Name): LIFESTYLES CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 LINDBERGH BLVD SUITE 110
FORT MYERS FL
33913-8827
US

IV. Provider business mailing address

11300 LINDBERGH BLVD SUITE 110
FORT MYERS FL
33913-8827
US

V. Phone/Fax

Practice location:
  • Phone: 239-334-9355
  • Fax: 239-334-9358
Mailing address:
  • Phone: 239-334-9355
  • Fax: 239-334-9358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCH9155
License Number StateFL

VIII. Authorized Official

Name: DR. TODD E WICKMANN
Title or Position: OWNER
Credential: D.C.
Phone: 239-334-9355