MEDICARE: CHIROPRACTICUSA OF LEESBURG, INC

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	CH5257	FL

General Provider Information

NPI Number	:	1649558297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTICUSA OF LEESBURG, INC

Provider Business Mailing Address
First Line	:	300 NW 70TH AVE
Second Line	:	SUITE 100
City	:	PLANTATION
State	:	FL
Zip	:	33317-2384
Country	:	US
Telephone Number	:	954-581-1999
Fax Number	:	954-581-3970

Provider Business Practice Location Address
First Line	:	945 N 14TH ST
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-3838
Country	:	US
Telephone Number	:	954-581-1999
Fax Number	:	954-581-3970

Authorized Official
Title or Position	:	CHIROPRACTOR/OWNER
Name	:	DR. RENNY MITCHELL EDELSON
Credential	:	D.C.
Telephone Number	:	954-581-1999

Provider Enumeration Date	:	08/01/2011
Last Update Date	:	08/01/2011

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