MEDICARE: WIDOM CHIROPRACTIC OFFICES PA

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	CH 6230	FL

General Provider Information

NPI Number	:	1558628123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIDOM CHIROPRACTIC OFFICES PA

Provider Business Mailing Address
First Line	:	5385 PARK CENTRAL CT
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34109-5932
Country	:	US
Telephone Number	:	239-596-9050
Fax Number	:

Provider Business Practice Location Address
First Line	:	5385 PARK CENTRAL CT
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34109-5932
Country	:	US
Telephone Number	:	239-596-9050
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GAVIN JAY WIDOM
Credential	:	DC
Telephone Number	:	239-263-3332

Provider Enumeration Date	:	04/19/2012
Last Update Date	:	10/22/2012

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Directions to “WIDOM CHIROPRACTIC OFFICES PA ” Practice Location

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