=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417616889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERRITT ISLAND CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2021
-----------------------------------------------------
Last Update Date | 12/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 PARNELL ST
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-4713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-453-6126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 PARNELL ST
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-4713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-453-6126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | DR. ROBERT WALTER TRAVEN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 321-453-6126
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------