MEDICARE: LEBANON CHIROPRACTIC CENTER

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	DC010295	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1316274285	OTHER	CA	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1700208212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEBANON CHIROPRACTIC CENTER

Provider Business Mailing Address
First Line	:	2234 CUMBERLAND ST
Second Line	:
City	:	LEBANON
State	:	PA
Zip	:	17042-2583
Country	:	US
Telephone Number	:	717-273-3741
Fax Number	:

Provider Business Practice Location Address
First Line	:	2234 CUMBERLAND ST
Second Line	:
City	:	LEBANON
State	:	PA
Zip	:	17042-2583
Country	:	US
Telephone Number	:	717-273-3741
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JARED STUBBLEFIELD
Credential	:
Telephone Number	:	717-273-3741

Provider Enumeration Date	:	01/17/2014
Last Update Date	:	01/17/2014

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