=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164743076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL ERICKSON D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2010
-----------------------------------------------------
Last Update Date | 06/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1873 WYNCOOP CREEK RD
-----------------------------------------------------
City | CHEMUNG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14825-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-846-8249
-----------------------------------------------------
Fax | 607-846-8249
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1873 WYNCOOP CREEK RD
-----------------------------------------------------
City | CHEMUNG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14825-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 123456
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------