MEDICARE: CHIROLAB 360 SPORT & SPINE 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	:	1700753613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROLAB 360 SPORT & SPINE PLLC

Provider Business Mailing Address
First Line	:	522 S HUNT CLUB BLVD # 201
Second Line	:
City	:	APOPKA
State	:	FL
Zip	:	32703-4960
Country	:	US
Telephone Number	:	407-756-9327
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 LAKE CENTER DR STE 4
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-2208
Country	:	US
Telephone Number	:	407-756-9327
Fax Number	:

Authorized Official
Title or Position	:	DC
Name	:	JASMINE NICOLE AMBROSIO
Credential	:
Telephone Number	:	407-756-9327

Provider Enumeration Date	:	10/23/2025
Last Update Date	:	01/26/2026

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