MEDICARE: GUDEMAN CHIROPRACTIC HEALTH CENTER, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH5573	FL

General Provider Information

NPI Number	:	1043503378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUDEMAN CHIROPRACTIC HEALTH CENTER, PA

Provider Business Mailing Address
First Line	:	562 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984-5108
Country	:	US
Telephone Number	:	772-340-2330
Fax Number	:	772-340-2331

Provider Business Practice Location Address
First Line	:	562 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984-5108
Country	:	US
Telephone Number	:	772-340-2330
Fax Number	:	772-340-2331

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MATTHEW JOHN GUDEMAN
Credential	:	DC
Telephone Number	:	772-340-2330

Provider Enumeration Date	:	05/19/2011
Last Update Date	:	05/19/2011

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