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General NPI Number Information
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NPI Number | 1679952634
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Entity Type | Organization
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Legal Business Name | BODY LOGIC CHIROPRACTIC, INC
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Dates
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Enumeration Date | 05/23/2015
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Last Update Date | 05/23/2015
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Provider Practice Location Address
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Address Line | 1880 N TAMIAMI TRL
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City | N FORT MYERS
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State | FL
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Zip | 33903-3366
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Country | US
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Telephone | 716-510-7007
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Fax |
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Provider Business Mailing Address
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Address Line | 145 CORDANA CT
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City | VENICE
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State | FL
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Zip | 34292-1313
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Country | US
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Telephone | 716-510-7007
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Fax |
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Authorized Official
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Title or Position | OWNER/ CHIROPRACTOR
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Name | DR. RAFFAELA VILLELLA
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Credential | D.C.
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Telephone | 716-510-7007
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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 | 9126
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License Number State | FL
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