=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558952226
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE SPINAL CARE & REHAB CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2021
-----------------------------------------------------
Last Update Date | 01/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8915 CONROY WINDERMERE RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-909-4788
-----------------------------------------------------
Fax | 407-909-1788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8915 CONROY WINDERMERE RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-909-4788
-----------------------------------------------------
Fax | 407-909-1788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | DR. GUILLERMO J NAZARIO NAZARIO
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 787-598-8601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------