MEDICARE: 30 CHIROPRACTIC

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	3197	NC

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

General Provider Information

NPI Number	:	1992063861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	30 CHIROPRACTIC

Provider Business Mailing Address
First Line	:	616 INDIAN TRAIL RD S
Second Line	:
City	:	INDIAN TRAIL
State	:	NC
Zip	:	28079-9680
Country	:	US
Telephone Number	:	704-821-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	616 INDIAN TRAIL RD S
Second Line	:
City	:	INDIAN TRAIL
State	:	NC
Zip	:	28079-9680
Country	:	US
Telephone Number	:	704-821-5000
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JOHN MONBARREN
Credential	:	DC
Telephone Number	:	704-821-5000

Provider Enumeration Date	:	04/30/2012
Last Update Date	:	04/30/2012

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Directions to “30 CHIROPRACTIC ” Practice Location

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