=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710257001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST SOUTHWEST MEDICAL REHAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2012
-----------------------------------------------------
Last Update Date | 01/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 BROADWAY SUITE D10
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-8193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-243-8925
-----------------------------------------------------
Fax | 239-245-8954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 61766
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33906-1766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-243-8925
-----------------------------------------------------
Fax | 239-245-8954
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID H IVEY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 239-243-8925
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9765
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------