MEDICARE: SPACE COAST SPINE 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

General Provider Information

NPI Number	:	1558911818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE COAST SPINE LLC.

Provider Business Mailing Address
First Line	:	1402 DUNLAWTON AVE STE 2B
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2917
Country	:	US
Telephone Number	:	386-227-6688
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 DUNLAWTON AVE STE 2B
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2917
Country	:	US
Telephone Number	:	386-227-6688
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL SAMBURSKY
Credential	:	D.C.
Telephone Number	:	386-281-7900

Provider Enumeration Date	:	09/18/2019
Last Update Date	:	12/04/2019

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Directions to “SPACE COAST SPINE LLC. ” Practice Location

Language	Start Address	Practice Location

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