MEDICARE: 1SPINE CHIROPRACTIC AND REHABILITATION OLDSMAR

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	CH8383	FL

General Provider Information

NPI Number	:	1477826840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1SPINE CHIROPRACTIC AND REHABILITATION OLDSMAR

Provider Business Mailing Address
First Line	:	3687 TAMPA RD
Second Line	:	SUITE 202
City	:	OLDSMAR
State	:	FL
Zip	:	34677-6307
Country	:	US
Telephone Number	:	813-220-0680
Fax Number	:

Provider Business Practice Location Address
First Line	:	3687 TAMPA RD
Second Line	:	SUITE 202
City	:	OLDSMAR
State	:	FL
Zip	:	34677-6307
Country	:	US
Telephone Number	:	813-220-0680
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTIC PHYSICIAN
Name	:	DR. NOAH RICHARD DANIEL
Credential	:	DC
Telephone Number	:	813-220-0680

Provider Enumeration Date	:	02/16/2012
Last Update Date	:	02/16/2012

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