MEDICARE: MONTGOMERY CHIROPRACTIC WELLNESS CENTER, 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	08002119A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000340468	OTHER	IN	BLUE SHIELD

General Provider Information

NPI Number	:	1558576827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTGOMERY CHIROPRACTIC WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	3818 NORTH 1ST AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47710-3326
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3818 NORTH 1ST AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47710-3326
Country	:	US
Telephone Number	:	812-424-7823
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICK MONTGOMERY
Credential	:	D.C.
Telephone Number	:	812-424-7823

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	10/06/2008

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