Healthcare Provider Details

I. General information

NPI: 1316936206
Provider Name (Legal Business Name): CHANNING C BOLICK DC, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E HORATIO AVE STE 5
MAITLAND FL
32751-7310
US

IV. Provider business mailing address

500 E HORATIO AVE STE 5
MAITLAND FL
32751-7310
US

V. Phone/Fax

Practice location:
  • Phone: 407-629-5333
  • Fax: 407-629-5343
Mailing address:
  • Phone: 407-629-5333
  • Fax: 407-629-5343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2398
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberCH7882
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6191
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH7882
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberCH7882
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: