MEDICARE: HOLISTIC INSTITUTE OF SO. FL, 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	CH1502	FL

General Provider Information

NPI Number	:	1356617955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLISTIC INSTITUTE OF SO. FL, INC

Provider Business Mailing Address
First Line	:	2480 SO. CONGRESS AVE.
Second Line	:	SUITE A-2
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-7615
Country	:	US
Telephone Number	:	561-641-7997
Fax Number	:	561-641-2461

Provider Business Practice Location Address
First Line	:	2480 SO. CONGRESS AVE
Second Line	:	SUITE A-2
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-7615
Country	:	US
Telephone Number	:	561-641-7997
Fax Number	:	561-641-2461

Authorized Official
Title or Position	:	PRES
Name	:	MR. JERRY ALLEN TANKERSLEY
Credential	:	D.C.
Telephone Number	:	561-641-7997

Provider Enumeration Date	:	03/28/2012
Last Update Date	:	03/28/2012

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