=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215067731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND PETER FERNANDEZ DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 12/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1619 6TH ST SE
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-3893
-----------------------------------------------------
Fax | 863-299-1315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1619 6TH ST SE
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-3893
-----------------------------------------------------
Fax | 863-299-1315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH6385
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------