Healthcare Provider Details

I. General information

NPI: 1356334718
Provider Name (Legal Business Name): SPACE COAST CORPORATE HEALTH SERVICE P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 PALM BAY RD NE STE 120
MELBOURNE FL
32904-8601
US

IV. Provider business mailing address

145 PALM BAY RD NE STE 120
MELBOURNE FL
32904-8601
US

V. Phone/Fax

Practice location:
  • Phone: 321-725-8778
  • Fax: 321-984-5299
Mailing address:
  • Phone: 321-725-8778
  • Fax: 321-984-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH4422
License Number StateFL

VIII. Authorized Official

Name: BRADLEY JE CLOW
Title or Position: PRESIDENT
Credential: DC
Phone: 321-725-8778