=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215352919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAWK NATION CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2014
-----------------------------------------------------
Last Update Date | 03/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 W MAIN ST STE 2
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52057-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-370-2784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 W MAIN ST SUITE 2
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52057-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-370-2784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | ZACHARY ROBERT LUJAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 563-370-2784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 072232
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 007735
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------