MEDICARE: BORINQUEN CHIROPRACTIC CLINIC 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	111NR0400X	Rehabilitation Chiropractor	12204	FL

General Provider Information

NPI Number	:	1245724483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BORINQUEN CHIROPRACTIC CLINIC INC.

Provider Business Mailing Address
First Line	:	9266 RANDAL PARK BLVD UNIT 16127
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32832-4944
Country	:	US
Telephone Number	:	407-751-3953
Fax Number	:	407-751-3953

Provider Business Practice Location Address
First Line	:	5462 HOFFNER AVE STE 504
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32812-2522
Country	:	US
Telephone Number	:	407-751-3953
Fax Number	:	407-751-3953

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANTHONY ROLDOS
Credential	:	DC
Telephone Number	:	407-751-3953

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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