=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841709946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAINESVILLE SPINE & INJURY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2017
-----------------------------------------------------
Last Update Date | 10/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7550 W UNIVERSITY AVE
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32607-7607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-732-5590
-----------------------------------------------------
Fax | 352-732-5590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1541 SE 17TH ST
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-732-5590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | JONATHAN RAY WALKER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 352-732-5590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9403
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------