=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194942987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | O MY-BACK,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 07/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 MAIN ST
-----------------------------------------------------
City | MILES CITY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59301-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-234-2964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 511 MAIN ST
-----------------------------------------------------
City | MILES CITY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59301-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-234-2964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENNETH P STEIN
-----------------------------------------------------
Credential | CCSP
-----------------------------------------------------
Telephone | 406-234-2964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 541
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------