MEDICARE: HEAVENLY TOUCH CHIROPRACTIC REHABILITATION

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
2	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1609241884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY TOUCH CHIROPRACTIC REHABILITATION

Provider Business Mailing Address
First Line	:	202 LAKE MIRIAM DR
Second Line	:	SUITE W-3
City	:	LAKELAND
State	:	FL
Zip	:	33813-2180
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 LAKE MIRIAM DR
Second Line	:	SUITE W-3
City	:	LAKELAND
State	:	FL
Zip	:	33813-2180
Country	:	US
Telephone Number	:	863-647-0808
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	KOTEUAISA WILSON
Credential	:
Telephone Number	:	863-647-0808

Provider Enumeration Date	:	12/14/2015
Last Update Date	:	12/14/2015

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Directions to “HEAVENLY TOUCH CHIROPRACTIC REHABILITATION ” Practice Location

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