MEDICARE: 100 CHIRO BAYLESS, PLLC

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	:	1619662046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	100 CHIRO BAYLESS, PLLC

Provider Business Mailing Address
First Line	:	1314 CALDERWOOD CT SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-3950
Country	:	US
Telephone Number	:	615-715-7983
Fax Number	:

Provider Business Practice Location Address
First Line	:	15280 S JOG RD STE D
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33446-2169
Country	:	US
Telephone Number	:	615-715-7983
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ CHIROPRACTOR
Name	:	DR. BENNETT BAYLESS
Credential	:	DC
Telephone Number	:	615-715-7983

Provider Enumeration Date	:	04/11/2023
Last Update Date	:	04/11/2023

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