Healthcare Provider Details

I. General information

NPI: 1558796979
Provider Name (Legal Business Name): HEALTHY SPINE AND MED SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11364 S ORANGE BLOSSOM TRL
ORLANDO FL
32837-9426
US

IV. Provider business mailing address

11364 S ORANGE BLOSSOM TRL
ORLANDO FL
32837-9426
US

V. Phone/Fax

Practice location:
  • Phone: 407-240-0661
  • Fax:
Mailing address:
  • Phone: 407-240-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: FIAZ JALEEL
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 407-240-0661