MEDICARE: BALLARD CENTRAL CHIROPRACTIC INC

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	CH00034175	WA

General Provider Information

NPI Number	:	1295935252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALLARD CENTRAL CHIROPRACTIC INC

Provider Business Mailing Address
First Line	:	5409 17TH AVE NW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-3818
Country	:	US
Telephone Number	:	206-784-3895
Fax Number	:	206-784-7471

Provider Business Practice Location Address
First Line	:	5409 17TH AVE NW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-3818
Country	:	US
Telephone Number	:	206-784-3895
Fax Number	:	206-784-7471

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRODIE I KLENK
Credential	:	DC
Telephone Number	:	206-784-3895

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	07/18/2007

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