=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154767135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEARWATER MEDICAL AND CONSULTING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2013
-----------------------------------------------------
Last Update Date | 03/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6166 SEMINOLE BLVD
-----------------------------------------------------
City | SEMINOLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33772-6835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-495-7246
-----------------------------------------------------
Fax | 727-495-7247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 272849
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33688-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-335-9669
-----------------------------------------------------
Fax | 813-793-4690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DOUGLAS PHILIP CLEARWATER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 813-335-9669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH8998
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------