=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134211170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES THOMAS MCCRORY M.D., D.C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 04/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 HARDING BLVD 213
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-780-2800
-----------------------------------------------------
Fax | 916-780-1130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 HARDING BLVD 213
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-780-2800
-----------------------------------------------------
Fax | 916-780-1130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC24046
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A066088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------