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General NPI Number Information
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NPI Number | 1790005569
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Entity Type | Organization
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Legal Business Name | SOUTHERN TRACE CHIROPRACTIC AND MASSAGE CENTER PA
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Dates
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Enumeration Date | 06/03/2010
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Last Update Date | 10/30/2014
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Provider Practice Location Address
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Address Line | 11834 COUNTY ROAD 101 SUITE 202
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City | THE VILLAGES
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State | FL
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Zip | 32162-9340
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Country | US
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Telephone | 352-205-8500
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Fax | 352-205-8603
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Provider Business Mailing Address
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Address Line | PO BOX 507
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City | BELLEVIEW
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State | FL
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Zip | 34421-0507
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Country | US
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Telephone | 352-205-8500
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Fax | 352-205-8603
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Authorized Official
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Title or Position | PRES
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Name | DR. MICHELLE MARIE ZIELECKI
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Credential | DC
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Telephone | 352-205-8500
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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 7914
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License Number State | FL
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