MEDICARE: PALM BAY CHIROPRACTIC AND WELLNESS, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH11572	OTHER	FL	CHIROPRACTIC LICENSE

General Provider Information

NPI Number	:	1780317040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM BAY CHIROPRACTIC AND WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	490 CENTRE LAKE DR NE STE 100A
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-1113
Country	:	US
Telephone Number	:	321-499-4608
Fax Number	:	321-499-4607

Provider Business Practice Location Address
First Line	:	490 CENTRE LAKE DR NE STE 100A
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-1113
Country	:	US
Telephone Number	:	321-499-4608
Fax Number	:	321-499-4607

Authorized Official
Title or Position	:	CHIROPRACTIC PHYSICIAN
Name	:	DR. DAVID M. DURKIN
Credential	:	D.C.
Telephone Number	:	321-499-4608

Provider Enumeration Date	:	07/05/2022
Last Update Date	:	11/21/2022

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