=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801427638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC & LONGEVITY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2020
-----------------------------------------------------
Last Update Date | 01/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 E. ELKAM CIRCLE UNIT B-11
-----------------------------------------------------
City | MARCO ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-315-1178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 E. ELKAM CIRCLE UNIT B-11
-----------------------------------------------------
City | MARCO ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-315-1178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. MICHAEL TERRY SHERMAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 239-315-1178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------