=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174167969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUNDY CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2019
-----------------------------------------------------
Last Update Date | 11/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4195 MANNHEIM RD
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47546-9625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-634-6000
-----------------------------------------------------
Fax | 812-634-7001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4195 MANNHEIM RD
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47546-9625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-634-6000
-----------------------------------------------------
Fax | 812-634-7001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LYDIA M MUNDY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 812-827-3940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------