MEDICARE: DR. SHANNON LEE BONE D.C.

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	1772	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4083899	OTHER	TN	BCBS NUMBER
2	3501260	OTHER	TN	CIGNA NUMBER

General Provider Information

NPI Number	:	1790756559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON LEE BONE D.C.

Provider Business Mailing Address
First Line	:	2012 GREYSTONE PARK
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3575
Country	:	US
Telephone Number	:	731-664-6998
Fax Number	:	731-664-7161

Provider Business Practice Location Address
First Line	:	2012 GREYSTONE PARK
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3575
Country	:	US
Telephone Number	:	731-664-6998
Fax Number	:	731-664-7161

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/09/2007

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