=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174861496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FERGUSON FAMILY CHIROPRACTIC AND WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2013
-----------------------------------------------------
Last Update Date | 02/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3313 LEE ST NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-4735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-493-7970
-----------------------------------------------------
Fax | 330-493-7410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3313 LEE ST NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-4735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-493-7970
-----------------------------------------------------
Fax | 330-493-7410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. BRIAN P FERGUSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 330-936-3082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4135
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3764
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------