MEDICARE: CENTRAL OHIO CLINIC OF 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	111N00000X	Chiropractor	3358	OH

General Provider Information

NPI Number	:	1912275421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL OHIO CLINIC OF CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	830 DELAWARE AVE
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-1724
Country	:	US
Telephone Number	:	937-645-9000
Fax Number	:	937-645-9000

Provider Business Practice Location Address
First Line	:	830 DELAWARE AVE
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-1724
Country	:	US
Telephone Number	:	937-645-9000
Fax Number	:	937-645-9000

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. BRETT JOSHUA BLITZSTEIN
Credential	:	D.C.
Telephone Number	:	937-645-9000

Provider Enumeration Date	:	12/12/2011
Last Update Date	:	12/12/2011

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