=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174867105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAINELY CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 12/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 SHORE RD BLDG. 326
-----------------------------------------------------
City | CAPE ELIZABETH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04107-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-650-2493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 SHORE RD BLDG. 326
-----------------------------------------------------
City | CAPE ELIZABETH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04107-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-650-2493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. COLLEEN ANNE MONROE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 207-650-2493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CR2069
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------