MEDICARE: FIRST STATE SPINAL REHABILITATION LLC

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	:	1710538319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST STATE SPINAL REHABILITATION LLC

Provider Business Mailing Address
First Line	:	9044 SE BRIDGE RD
Second Line	:
City	:	HOBE SOUND
State	:	FL
Zip	:	33455-5313
Country	:	US
Telephone Number	:	772-546-9591
Fax Number	:	772-546-9535

Provider Business Practice Location Address
First Line	:	2500 W 4TH ST STE 4
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19805-3352
Country	:	US
Telephone Number	:	772-546-9591
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. JENEANE MARIE WAKULA
Credential	:
Telephone Number	:	772-546-9591

Provider Enumeration Date	:	09/25/2019
Last Update Date	:	09/25/2019

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