=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841625464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE RECOVERY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2013
-----------------------------------------------------
Last Update Date | 09/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 CYPRESS POINT PARKWAY SUITE #103
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-233-3265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6684 MERRYVALE LANE
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-233-3265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. HARRY VASSILAKIS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 386-212-8612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH8852
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------