Provider Demographics
NPI:1558453662
Name:MCGOWAN SPINAL REHABILITATION CENTER PA
Entity type:Organization
Organization Name:MCGOWAN SPINAL REHABILITATION CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-350-5544
Mailing Address - Street 1:PO BOX 17809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7809
Mailing Address - Country:US
Mailing Address - Phone:904-723-0015
Mailing Address - Fax:904-338-0951
Practice Address - Street 1:3021 MAIN ST N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-6168
Practice Address - Country:US
Practice Address - Phone:904-350-5544
Practice Address - Fax:904-350-9944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8235111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40249OtherBCBS