=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023137239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADEIRA CHIROPRACTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7843 LAUREL AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45243-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-272-3553
-----------------------------------------------------
Fax | 513-272-1189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7843 LAUREL AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45243-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER WALKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-272-3553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2516
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------