MEDICARE: DAVIDSON CHIROPRACTIC CLINIC - EVANSTON LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor		WY

General Provider Information

NPI Number	:	1023502408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIDSON CHIROPRACTIC CLINIC - EVANSTON LLC

Provider Business Mailing Address
First Line	:	195 FEATHER WAY STE A
Second Line	:
City	:	EVANSTON
State	:	WY
Zip	:	82930-9352
Country	:	US
Telephone Number	:	307-382-0600
Fax Number	:	307-382-0601

Provider Business Practice Location Address
First Line	:	195 FEATHER WAY STE A
Second Line	:
City	:	EVANSTON
State	:	WY
Zip	:	82930-9352
Country	:	US
Telephone Number	:	307-382-0600
Fax Number	:	307-382-0601

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	DR. MICHAEL AARON DAVIDSON
Credential	:	DC
Telephone Number	:	307-382-0600

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	06/19/2018

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