Healthcare Provider Details

I. General information

NPI: 1063653707
Provider Name (Legal Business Name): FLORIDA SPINE AND DISC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 03/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 SE VILLAGE GREEN DR STE B
PORT ST LUCIE FL
34952-5118
US

IV. Provider business mailing address

1401 SE VILLAGE GREEN DR STE B
PORT ST LUCIE FL
34952-5118
US

V. Phone/Fax

Practice location:
  • Phone: 772-878-3955
  • Fax: 772-340-7716
Mailing address:
  • Phone: 772-878-3955
  • Fax: 772-340-7716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH7777
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT20041
License Number StateFL

VIII. Authorized Official

Name: DR. CARL JOHN ABENDROTH
Title or Position: PRESIDENT
Credential: D.C.
Phone: 772-878-3955