=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023374683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMPBELLSVILLE CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2012
-----------------------------------------------------
Last Update Date | 07/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 E MAPLE ST
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-1830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-789-0033
-----------------------------------------------------
Fax | 270-789-0038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 E MAPLE ST
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-1830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-789-0033
-----------------------------------------------------
Fax | 270-789-0038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SAMUEL L YODER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 270-789-0033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5318
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------