MEDICARE: PERCELL J SANDERS III 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	CH12620	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH12620	OTHER	FL	MEDICAL LICENSE

General Provider Information

NPI Number	:	1124594791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PERCELL J SANDERS III DC

Provider Business Mailing Address
First Line	:	3021 N MAIN ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-2122
Country	:	US
Telephone Number	:	904-350-5544
Fax Number	:	904-350-9944

Provider Business Practice Location Address
First Line	:	3021 N MAIN ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-2122
Country	:	US
Telephone Number	:	904-350-5544
Fax Number	:	904-350-9944

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

Provider Enumeration Date	:	10/22/2018
Last Update Date	:	10/22/2018

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