MEDICARE: COLUMBIA COUNTY CHIROPRACTIC CENTER, LLC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NX0800X	Orthopedic Chiropractor	CH5141	FL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CL2214	OTHER	FL	RAILROAD MEDICARE GROUP #

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1467652578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA COUNTY CHIROPRACTIC CENTER, LLC

Provider Business Mailing Address
First Line	:	279 SW MAIN BLVD
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-7050
Country	:	US
Telephone Number	:	386-752-4313
Fax Number	:	386-752-8356

Provider Business Practice Location Address
First Line	:	279 SW MAIN BLVD
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-7050
Country	:	US
Telephone Number	:	386-752-4313
Fax Number	:	386-752-8356

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. DARREL THOMAS MATHIS
Credential	:	D.C.
Telephone Number	:	386-752-4313

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	03/24/2017

279 SW MAIN BLVD
LAKE CITY, FL
32025-7050

Practice Phone: 386-752-4313
Practice Fax: 386-752-8356