MEDICARE: PROVIDENCE CHIROPRACTIC, 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

General Provider Information

NPI Number	:	1245571561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	3071 HIGHWAY 21 BYP
Second Line	:	SUITE 103
City	:	FORT MILL
State	:	SC
Zip	:	29715-7205
Country	:	US
Telephone Number	:	803-835-0444
Fax Number	:	803-835-0489

Provider Business Practice Location Address
First Line	:	3071 HIGHWAY 21 BYP
Second Line	:	SUITE 103
City	:	FORT MILL
State	:	SC
Zip	:	29715-7205
Country	:	US
Telephone Number	:	803-835-0444
Fax Number	:	803-835-0489

Authorized Official
Title or Position	:	PROVIDER
Name	:	DR. JESSICA M HARDEN
Credential	:	DC
Telephone Number	:	803-835-0444

Provider Enumeration Date	:	03/12/2013
Last Update Date	:	03/12/2013

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