MEDICARE: SPACE COAST CORPORATE HEALTH SERVICE P A

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	CH4422	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34121	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1356334718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE COAST CORPORATE HEALTH SERVICE P A

Provider Business Mailing Address
First Line	:	145 PALM BAY RD NE
Second Line	:	STE 120
City	:	MELBOURNE
State	:	FL
Zip	:	32904-8601
Country	:	US
Telephone Number	:	321-725-8778
Fax Number	:	321-984-5299

Provider Business Practice Location Address
First Line	:	145 PALM BAY RD NE
Second Line	:	STE 120
City	:	MELBOURNE
State	:	FL
Zip	:	32904-8601
Country	:	US
Telephone Number	:	321-725-8778
Fax Number	:	321-984-5299

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRADLEY JE CLOW
Credential	:	DC
Telephone Number	:	321-725-8778

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	08/23/2024

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