Provider Demographics
NPI:1841520756
Name:CHIROPRACTIC ACCIDENT AND INJURY CENTER
Entity type:Organization
Organization Name:CHIROPRACTIC ACCIDENT AND INJURY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:WIDOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-267-3332
Mailing Address - Street 1:1400 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1055
Mailing Address - Country:US
Mailing Address - Phone:239-267-3332
Mailing Address - Fax:
Practice Address - Street 1:1400 COLONIAL BLVD STE 31
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1053
Practice Address - Country:US
Practice Address - Phone:230-267-3332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty