MEDICARE: DECOMPRESSION AND SPINAL REHAB OF SWFL

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	CH7598	FL
2	332B00000X	Durable Medical Equipment & Medical Supplies	6185490001	FL
3	225100000X	Physical Therapist	PT4617	FL

General Provider Information

NPI Number	:	1891991386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DECOMPRESSION AND SPINAL REHAB OF SWFL

Provider Business Mailing Address
First Line	:	16517 VANDERBILT DR
Second Line	:	SUITE 1
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7550
Country	:	US
Telephone Number	:	239-947-7844
Fax Number	:	239-947-6338

Provider Business Practice Location Address
First Line	:	16517 VANDERBILT DR
Second Line	:	SUITE 1
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7550
Country	:	US
Telephone Number	:	239-947-7844
Fax Number	:	239-947-6338

Authorized Official
Title or Position	:	CLINIC DIRECTOR
Name	:	DR. DAN BARTLEY
Credential	:	D.C.
Telephone Number	:	239-947-7844

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	07/09/2009

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