=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831692904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PELLETIERE FAMILY CHIROPRACTIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2018
-----------------------------------------------------
Last Update Date | 03/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3411 BONITA BEACH RD STE 302
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-4155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-949-1222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3411 BONITA BEACH RD STE 302
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-4155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-949-1222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. MICHELE PELLETIERE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 239-949-1222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH7472
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------