MEDICARE: CORE 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	261Q00000X	Clinic/Center	CHR.0007486	CO

General Provider Information

NPI Number	:	1407307523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORE CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	4730 CENTENNIAL BLVD
Second Line	:	102
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3338
Country	:	US
Telephone Number	:	719-217-7453
Fax Number	:

Provider Business Practice Location Address
First Line	:	4730 CENTENNIAL BLVD
Second Line	:	102
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3338
Country	:	US
Telephone Number	:	719-258-8349
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KAILE RYAN MYRICK
Credential	:	D.C.
Telephone Number	:	719-217-7453

Provider Enumeration Date	:	10/24/2016
Last Update Date	:	12/14/2016

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