Healthcare Provider Details

I. General information

NPI: 1194771808
Provider Name (Legal Business Name): PALM COAST SPINE AND REHAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2699 LEE RD SUITE 505
WINTER PARK FL
32789-1753
US

IV. Provider business mailing address

2699 LEE RD SUITE 505
WINTER PARK FL
32789-1753
US

V. Phone/Fax

Practice location:
  • Phone: 407-960-3775
  • Fax: 407-960-3652
Mailing address:
  • Phone: 407-960-3775
  • Fax: 407-960-3652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J DEMCHAK
Title or Position: PRESIDENT
Credential: DC
Phone: 407-960-3775