=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205284106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELECT MED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2016
-----------------------------------------------------
Last Update Date | 06/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21321 E OCOTILLO RD STE 125
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-5996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-677-4800
-----------------------------------------------------
Fax | 480-436-6667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21321 E OCOTILLO RD STE 125
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-5996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-677-4800
-----------------------------------------------------
Fax | 480-436-6667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | BRET ERDMANN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 480-677-4800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8081
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------