=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184617748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELSH CLINIC OF CHIROPRACTIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2005
-----------------------------------------------------
Last Update Date | 01/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5121 EHRLICH RD ST 109
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33624-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-962-2489
-----------------------------------------------------
Fax | 813-962-8781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5121 EHRLICH RD ST 109
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33624-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-962-2489
-----------------------------------------------------
Fax | 813-962-8781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. SUSAN WELSH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 813-962-2489
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038004210
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 08000863
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH3746
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------