NPIMap

Organization Active NPI

Experience Family Chiropractic

  • Chiropractor
  • Cape Coral, FL
National Provider Identifier
1447794342
Registry record updated Dec 12, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
ChiropractorTaxonomy code 111N00000X
License
CH11971 Issued in FL
Legal business name
EXPERIENCE FAMILY CHIROPRACTIC
Practice address
2378 Surfside Blvd
Suite A133
Cape Coral, FL 33991-3181
Phone
(239) 205-3700
NPI assigned
Dec 12, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Omar-Shay Clark, DCNPI 1457895351
Title
Owner
Phone
(239) 205-3700

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
ChiropractorGroup: 193400000X SINGLE SPECIALTY GROUP 111N00000X CH11971 FL Primary

Addresses

Primary practice location

2378 Surfside Blvd
Suite A133
Cape Coral, FL 33991-3181

Mailing address

2378 Surfside Blvd
Suite A133
Cape Coral, FL 33991-3181
Phone (239) 205-3700

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170121000022 FL Part B Supplier - Clinic/Group Practice 1153603444 Receives reassigned benefits from 3 practitioners
Practice locations: Cape Coral, FL

National Provider Directory

National Provider Directory

Locations

2307 Sandoval Blvd
Ste 3
Cape Coral, FL 33991
Phone (239) 205-3700

2378 Surfside Blvd
Ste A133
Cape Coral, FL 33991
Phone (239) 205-3700

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1481500800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1481500800000",
    "number": "1447794342",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2378 SURFSIDE BLVD",
            "address_2": "SUITE A133",
            "city": "CAPE CORAL",
            "state": "FL",
            "postal_code": "339913181",
            "telephone_number": "239-205-3700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2378 SURFSIDE BLVD",
            "address_2": "SUITE A133",
            "city": "CAPE CORAL",
            "state": "FL",
            "postal_code": "339913181",
            "telephone_number": "239-205-3700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXPERIENCE FAMILY CHIROPRACTIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-12-12",
        "last_updated": "2016-12-12",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "OMAR-SHAY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "239-205-3700",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DC"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Chiropractor",
            "state": "FL",
            "license": "CH11971",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cape Coral, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.