=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245724483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BORINQUEN CHIROPRACTIC CLINIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2018
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5462 HOFFNER AVE STE 504
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32812-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-751-3953
-----------------------------------------------------
Fax | 407-751-3953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9266 RANDAL PARK BLVD UNIT 16127
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-4944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-751-3953
-----------------------------------------------------
Fax | 407-751-3953
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANTHONY ROLDOS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 407-751-3953
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 12204
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------