Healthcare Provider Details

I. General information

NPI: 1558453662
Provider Name (Legal Business Name): MCGOWAN SPINAL REHABILITATION CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 MAIN ST N
JACKSONVILLE FL
32206-6168
US

IV. Provider business mailing address

PO BOX 17809
JACKSONVILLE FL
32245-7809
US

V. Phone/Fax

Practice location:
  • Phone: 904-350-5544
  • Fax: 904-350-9944
Mailing address:
  • Phone: 904-723-0015
  • Fax: 904-338-0951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8235
License Number StateFL

VIII. Authorized Official

Name: SHELITA MCGOWAN
Title or Position: PRESIDENT
Credential: D.C.
Phone: 904-350-5544