=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174874929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESOLUTION PAIN RELIEF
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2012
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 591 REDWOOD HWY STE 2300
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-389-9000
-----------------------------------------------------
Fax | 415-389-7912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 591 REDWOOD HWY STE 2300
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-389-9000
-----------------------------------------------------
Fax | 415-389-7912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JESPER LUNDBAEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-389-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 22400
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------