MEDICARE: KIM A. REDDICK, DC, 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	363L00000X	Nurse Practitioner
2	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1841382561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM A. REDDICK, DC, LLC

Provider Business Mailing Address
First Line	:	2415 S VOLUSIA AVE STE A2
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-7623
Country	:	US
Telephone Number	:	386-775-6879
Fax Number	:	386-775-0307

Provider Business Practice Location Address
First Line	:	2415 S VOLUSIA AVE STE A2
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-7623
Country	:	US
Telephone Number	:	386-775-6879
Fax Number	:	386-775-0307

Authorized Official
Title or Position	:	CLINIC DIRECTOR
Name	:	DR. LEONARD A. ROLLMAN
Credential	:	DC
Telephone Number	:	386-775-6879

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	09/03/2021

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