MEDICARE: LAKE CHARLESTON HEALTH CENTER, 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

General Provider Information

NPI Number	:	1538387188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE CHARLESTON HEALTH CENTER, P.A.

Provider Business Mailing Address
First Line	:	7026 CHARLESTON SHORES BLVD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-7628
Country	:	US
Telephone Number	:	561-432-6021
Fax Number	:

Provider Business Practice Location Address
First Line	:	7026 CHARLESTON SHORES BLVD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-7628
Country	:	US
Telephone Number	:	561-432-6021
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD JOSEPH RIDKY
Credential	:	DC
Telephone Number	:	561-432-6021

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	05/17/2011

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