=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174849202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EWERT CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2010
-----------------------------------------------------
Last Update Date | 09/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 N BALTIMORE SUITE B
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67037-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-788-7500
-----------------------------------------------------
Fax | 316-788-7702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 N BALTIMORE SUITE B
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67037-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-788-7500
-----------------------------------------------------
Fax | 316-788-7702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MINDY DIANE EWERT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 316-461-2013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 01-05288
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------