=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194147330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLESTON CHIROPRACTIC COMPANY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2014
-----------------------------------------------------
Last Update Date | 01/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 713 BIGLEY AVE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25302-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-344-2225
-----------------------------------------------------
Fax | 304-344-2226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 BIGLEY AVE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25302-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-344-2225
-----------------------------------------------------
Fax | 304-344-2226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | DR. JENNIFER BULGER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 304-344-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 944
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------