MEDICARE: GULFSHORE SPINAL CARE, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH11188	OTHER	FL	CHIROPRACTIC LICENSE

General Provider Information

NPI Number	:	1528650363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULFSHORE SPINAL CARE, LLC

Provider Business Mailing Address
First Line	:	5256 SUMMERLIN COMMONS WAY STE 204
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2147
Country	:	US
Telephone Number	:	239-204-9987
Fax Number	:

Provider Business Practice Location Address
First Line	:	5256 SUMMERLIN COMMONS WAY STE 204
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2147
Country	:	US
Telephone Number	:	239-204-9987
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	DR. MICHAEL KNECHT
Credential	:	DC
Telephone Number	:	810-533-1455

Provider Enumeration Date	:	02/03/2021
Last Update Date	:	02/03/2021

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