=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104053149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2009
-----------------------------------------------------
Last Update Date | 06/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 E. MONGOMERY ST.
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50138-2240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-842-2239
-----------------------------------------------------
Fax | 641-842-2239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 E. MONGOMERY ST.
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50138-2240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-842-2239
-----------------------------------------------------
Fax | 641-842-2239
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. EDWARD SCOTT COYLE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 641-842-2239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | A05960
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------