=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083633200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAYNE CHIROPRACTIC LIFE CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4014 COMMONS DR W UNIT 114
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541-8423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-654-8770
-----------------------------------------------------
Fax | 850-654-1056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4014 COMMONS DR W UNIT 114
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541-8423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-654-8770
-----------------------------------------------------
Fax | 850-654-1056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR.
-----------------------------------------------------
Name | DR. ALAN M PAYNE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 850-654-8770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH0006929
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------