MEDICARE: SPINE LABS

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	:	1932921632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE LABS

Provider Business Mailing Address
First Line	:	425 S AVALON PARK BLVD STE 900
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-6702
Country	:	US
Telephone Number	:	407-805-1170
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 S AVALON PARK BLVD STE 900
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-6702
Country	:	US
Telephone Number	:	407-805-1170
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IVI BIFSHA
Credential	:
Telephone Number	:	407-805-1170

Provider Enumeration Date	:	10/25/2024
Last Update Date	:	10/25/2024

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Directions to “SPINE LABS ” Practice Location

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