Provider Demographics
NPI:1295268910
Name:GULFSIDE CHIROPRACTIC HEALTH CENTER
Entity type:Organization
Organization Name:GULFSIDE CHIROPRACTIC HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KREG
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:239-908-9762
Mailing Address - Street 1:9138 BONITA BEACH RD SE
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4291
Mailing Address - Country:US
Mailing Address - Phone:239-908-9762
Mailing Address - Fax:
Practice Address - Street 1:9138 BONITA BEACH RD SE
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4291
Practice Address - Country:US
Practice Address - Phone:239-908-9762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12151111N00000X
FLCH 12155111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty