MEDICARE: COLONIAL 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

General Provider Information

NPI Number	:	1770139933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL CHIROPRACTIC, INC

Provider Business Mailing Address
First Line	:	1570 COLONIAL BLVD STE B
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1031
Country	:	US
Telephone Number	:	239-936-2144
Fax Number	:	239-936-7276

Provider Business Practice Location Address
First Line	:	1570 COLONIAL BLVD STE B
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1031
Country	:	US
Telephone Number	:	239-936-2144
Fax Number	:	239-936-7276

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSE VASCONCELLOS
Credential	:	DC
Telephone Number	:	239-936-2144

Provider Enumeration Date	:	08/14/2019
Last Update Date	:	09/18/2019

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