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General NPI Number Information
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NPI Number | 1558628123
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Entity Type | Organization
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Legal Business Name | WIDOM CHIROPRACTIC OFFICES PA
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Dates
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Enumeration Date | 04/19/2012
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Last Update Date | 10/22/2012
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Provider Practice Location Address
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Address Line | 5385 PARK CENTRAL CT
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City | NAPLES
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State | FL
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Zip | 34109-5932
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Country | US
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Telephone | 239-596-9050
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Fax |
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Provider Business Mailing Address
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Address Line | 5385 PARK CENTRAL CT
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City | NAPLES
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State | FL
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Zip | 34109-5932
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Country | US
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Telephone | 239-596-9050
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. GAVIN JAY WIDOM
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Credential | DC
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Telephone | 239-263-3332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH 6230
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License Number State | FL
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