MEDICARE: COLISEUM CHIROPRACTIC

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

General Provider Information

NPI Number	:	1164677480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLISEUM CHIROPRACTIC

Provider Business Mailing Address
First Line	:	1184 W PIONEER PKWY
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-6367
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	916 W COLISEUM BLVD STE F
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-1291
Country	:	US
Telephone Number	:	260-373-2225
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BUFFIE MIKE CAPOBIANCO
Credential	:
Telephone Number	:	260-373-2225

Provider Enumeration Date	:	12/01/2008
Last Update Date	:	12/01/2008

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