=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124362876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOCA CHIROPRACTIC SPINE & HEADACHE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2012
-----------------------------------------------------
Last Update Date | 11/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 GLADES RD SUITE 430W
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-7386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-929-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 GLADES RD SUITE 430W
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-7386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-929-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JONATHAN ROUFFE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 561-929-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH10479
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------