MEDICARE: CENTRAL FLORIDA INTEGRATED WELLNESS CLINIC PLLC

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	CH7882	FL
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	ME45785	FL

General Provider Information

NPI Number	:	1265727861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL FLORIDA INTEGRATED WELLNESS CLINIC PLLC

Provider Business Mailing Address
First Line	:	500 E HORATIO AVE
Second Line	:	SUITE 5
City	:	MAITLAND
State	:	FL
Zip	:	32751-7310
Country	:	US
Telephone Number	:	407-629-5333
Fax Number	:	407-629-5343

Provider Business Practice Location Address
First Line	:	500 E HORATIO AVE
Second Line	:	SUITE 5
City	:	MAITLAND
State	:	FL
Zip	:	32751-7310
Country	:	US
Telephone Number	:	407-629-5333
Fax Number	:	407-629-5343

Authorized Official
Title or Position	:	MGR
Name	:	DR. CHANNING C. BOLICK
Credential	:	D.C.
Telephone Number	:	407-629-5333

Provider Enumeration Date	:	06/13/2011
Last Update Date	:	06/13/2011

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