Provider Demographics
NPI:1265509517
Name:BAGNELL, MICHAEL KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEITH
Last Name:BAGNELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9044 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1928
Mailing Address - Country:US
Mailing Address - Phone:305-259-8755
Mailing Address - Fax:305-252-9849
Practice Address - Street 1:9044 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1928
Practice Address - Country:US
Practice Address - Phone:305-259-8755
Practice Address - Fax:305-252-9849
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5986111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22508Medicare UPIN