=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972371920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONQUER HEALTH CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2023
-----------------------------------------------------
Last Update Date | 01/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 STATE ROAD 13 S UNIT 2
-----------------------------------------------------
City | ST JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-3865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-870-8701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 STATE ROAD 13 S UNIT 2
-----------------------------------------------------
City | ST JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-3865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-870-8701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CRAIG BRYAN III
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 904-870-8701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------