=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184020497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOFFMAN SPORTS CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2014
-----------------------------------------------------
Last Update Date | 12/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11521 FISHERS DR
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46038-1860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-213-1246
-----------------------------------------------------
Fax | 317-842-8522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 410
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46082-0410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-213-1246
-----------------------------------------------------
Fax | 317-842-8522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREW T HOFFMAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 317-213-1246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 08002336A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------