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General NPI Number Information
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NPI Number | 1841520756
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Entity Type | Organization
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Legal Business Name | CHIROPRACTIC ACCIDENT AND INJURY CENTER
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Dates
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Enumeration Date | 12/29/2009
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Last Update Date | 12/29/2009
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Provider Practice Location Address
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Address Line | 1400 COLONIAL BLVD STE 31
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City | FORT MYERS
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State | FL
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Zip | 33907-1053
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Country | US
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Telephone | 230-267-3332
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Fax |
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Provider Business Mailing Address
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Address Line | 1400 COLONIAL BLVD
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City | FORT MYERS
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State | FL
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Zip | 33907-1055
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Country | US
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Telephone | 239-267-3332
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Fax |
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. GAVIN JAY WIDOM
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Credential | D.C.
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Telephone | 239-267-3332
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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 | CH6230
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License Number State | FL
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