Provider Demographics
NPI:1184946691
Name:SPINAL HEALTH AND REHAB OF PUNTA GORDA
Entity type:Organization
Organization Name:SPINAL HEALTH AND REHAB OF PUNTA GORDA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:VAN NOSTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:BS DC
Authorized Official - Phone:941-205-2180
Mailing Address - Street 1:324 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-4828
Mailing Address - Country:US
Mailing Address - Phone:941-205-2180
Mailing Address - Fax:941-205-2181
Practice Address - Street 1:324 CROSS ST
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-4828
Practice Address - Country:US
Practice Address - Phone:941-205-2180
Practice Address - Fax:941-205-2181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 332B00000X, 111NR0400X
FLME102997207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003114900Medicaid
FL003114900Medicaid