Healthcare Provider Details

I. General information

NPI: 1275502098
Provider Name (Legal Business Name): SUNSHINE STATE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 S SEMORAN BLVD #503
ORLANDO FL
32822
US

IV. Provider business mailing address

5575 S SEMORAN BLVD #503
ORLANDO FL
32822
US

V. Phone/Fax

Practice location:
  • Phone: 407-482-0052
  • Fax: 407-482-0198
Mailing address:
  • Phone: 407-482-0052
  • Fax: 407-482-0198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9030
License Number StateFL

VIII. Authorized Official

Name: MARTHA ORTIZ
Title or Position: OWNER
Credential:
Phone: 407-482-0052