=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013415629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDLAND CHIROPRACTIC AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2018
-----------------------------------------------------
Last Update Date | 01/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 332 E MAIN ST
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25541-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-948-5979
-----------------------------------------------------
Fax | 681-233-0001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 332 E MAIN ST
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25541-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 681-233-0001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW LANE HARBOUR
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 304-948-5979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 984
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------