Provider Demographics
NPI:1104215706
Name:ORLANDO SPINE AND WELLNESS CENTER
Entity Type:Organization
Organization Name:ORLANDO SPINE AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THORN
Authorized Official - Last Name:BOWERMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:407-446-6687
Mailing Address - Street 1:13802 LANDSTAR BLVD
Mailing Address - Street 2:107
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5500
Mailing Address - Country:US
Mailing Address - Phone:321-234-0124
Mailing Address - Fax:321-280-1029
Practice Address - Street 1:13802 LANDSTAR BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-5500
Practice Address - Country:US
Practice Address - Phone:321-234-0124
Practice Address - Fax:321-280-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11337111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty