MEDICARE: MILLPOND FAMILY 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	5317	KY

General Provider Information

NPI Number	:	1396016085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLPOND FAMILY CHIROPRACTIC

Provider Business Mailing Address
First Line	:	3650 BOSTON RD
Second Line	:	SUITE E
City	:	LEXINGTON
State	:	KY
Zip	:	40514-1569
Country	:	US
Telephone Number	:	925-487-0253
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 BOSTON RD
Second Line	:	SUITE E
City	:	LEXINGTON
State	:	KY
Zip	:	40514-1569
Country	:	US
Telephone Number	:	925-487-0253
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHANNON PEARCE
Credential	:	D.C.
Telephone Number	:	925-487-0253

Provider Enumeration Date	:	01/26/2012
Last Update Date	:	01/26/2012

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