=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013105162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANTER CHIROPRACTIC LIFE CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2007
-----------------------------------------------------
Last Update Date | 10/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 E 4TH ST
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44622-2923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-343-2236
-----------------------------------------------------
Fax | 330-343-2300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 E 4TH ST
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44622-2923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-343-2236
-----------------------------------------------------
Fax | 330-343-2300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KENNETH WARREN CANTER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 330-343-2236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1176
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------