=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841347689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL CHIROPRACTIC CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5030 DR PHILLIPS BLVD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-291-2889
-----------------------------------------------------
Fax | 407-291-2994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5030 DR PHILLIPS BLVD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-291-2889
-----------------------------------------------------
Fax | 407-291-2994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. STEVEN K. NEWTON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 407-291-2889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH5869
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------