=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902226129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINTER PARK SPINE & INJURY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2014
-----------------------------------------------------
Last Update Date | 09/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5502 LAKE HOWELL RD
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-1036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-671-1256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5502 LAKE HOWELL RD
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-1036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-671-1256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | DR. REX ROFFLER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 407-671-1256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH 2545
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------