Provider Demographics
NPI:1154076222
Name:THE INJURY CLINIC OF FT MYERS LLC
Entity Type:Organization
Organization Name:THE INJURY CLINIC OF FT MYERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-689-8488
Mailing Address - Street 1:9858 CLINT MOORE RD # C111-274
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-1034
Mailing Address - Country:US
Mailing Address - Phone:561-482-1144
Mailing Address - Fax:561-482-1145
Practice Address - Street 1:12640 WORLD PLAZA LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3987
Practice Address - Country:US
Practice Address - Phone:239-689-8488
Practice Address - Fax:239-243-8149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty