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General NPI Number Information
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NPI Number | 1235314071
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Entity Type | Organization
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Legal Business Name | RETTAY CHIROPRACTIC OFFICE PSC
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Dates
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Enumeration Date | 12/28/2007
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Last Update Date | 12/11/2009
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Provider Practice Location Address
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Address Line | 7560 B BURLINGTON PIKE
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City | FLORENCE
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State | KY
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Zip | 41042-9634
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Country | US
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Telephone | 859-525-7117
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Fax | 859-282-3343
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Provider Business Mailing Address
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Address Line | PO BOX 547 7560 B BURLINGTON PIKE
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City | FLORENCE
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State | KY
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Zip | 41042-9634
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Country | US
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Telephone | 859-525-7117
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Fax | 859-282-3343
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. LAWRENCE MIKKELSON
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Credential | D.C.
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Telephone | 859-525-7117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 4396
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License Number State | KY
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