MEDICARE: JAMES MELBOURNE TAIT IV DC

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	0104557435	VA

General Provider Information

NPI Number	:	1366951360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES MELBOURNE TAIT IV DC

Provider Business Mailing Address
First Line	:	101 N STAFFORD AVE APT 10
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220-4454
Country	:	US
Telephone Number	:	804-516-0822
Fax Number	:

Provider Business Practice Location Address
First Line	:	4911 AUGUSTA AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-3601
Country	:	US
Telephone Number	:	804-254-0200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2017
Last Update Date	:	09/22/2017

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