MEDICARE: BODY LOGIC CHIROPRACTIC, 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	9126	FL

General Provider Information

NPI Number	:	1679952634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY LOGIC CHIROPRACTIC, INC

Provider Business Mailing Address
First Line	:	145 CORDANA CT
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34292-1313
Country	:	US
Telephone Number	:	716-510-7007
Fax Number	:

Provider Business Practice Location Address
First Line	:	1880 N TAMIAMI TRL
Second Line	:
City	:	N FORT MYERS
State	:	FL
Zip	:	33903-3366
Country	:	US
Telephone Number	:	716-510-7007
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ CHIROPRACTOR
Name	:	DR. RAFFAELA VILLELLA
Credential	:	D.C.
Telephone Number	:	716-510-7007

Provider Enumeration Date	:	05/23/2015
Last Update Date	:	05/23/2015

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