MEDICARE: MARVIN TERRY DC

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	CH6604	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	55176	OTHER	FL	BLUE CROSS- BLUE SHIELD

General Provider Information

NPI Number	:	1124159132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVIN TERRY DC

Provider Business Mailing Address
First Line	:	2295 S HIAWASSEE RD STE 205
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-8748
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2295 S HIAWASSEE RD STE 205
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-8748
Country	:	US
Telephone Number	:	407-298-3090
Fax Number	:	321-293-0111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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Directions to “ MARVIN TERRY DC” Practice Location

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