=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265427447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE SIMON DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2005
-----------------------------------------------------
Last Update Date | 04/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 E GIBSON ST
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34266-5011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-993-0100
-----------------------------------------------------
Fax | 863-993-2116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 997
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34220-0997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-776-4000
-----------------------------------------------------
Fax | 941-845-4963
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH3233
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------