=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316507502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRUCTURAL SPINAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2019
-----------------------------------------------------
Last Update Date | 12/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12251 TAFT ST STE 403
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-397-9083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12251 TAFT ST STE 403
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-397-9083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | DR. JASON SLAGEL
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 309-397-9083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------