MEDICARE: SOUTHWEST FLORIDA SPINE AND JOINT INC

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

General Provider Information

NPI Number	:	1235800343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST FLORIDA SPINE AND JOINT INC

Provider Business Mailing Address
First Line	:	25 HOMESTEAD RD N STE 5
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-6600
Country	:	US
Telephone Number	:	239-579-4444
Fax Number	:	239-579-4445

Provider Business Practice Location Address
First Line	:	25 HOMESTEAD RD N STE 5
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-6600
Country	:	US
Telephone Number	:	239-579-4444
Fax Number	:	239-579-4445

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. IVAN ROBERT BRACIC
Credential	:	DC
Telephone Number	:	239-579-4444

Provider Enumeration Date	:	09/28/2021
Last Update Date	:	09/28/2021

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