=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245255017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A ADDANTE D.C., CCSP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 05/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 OAK ST UNIT 2
-----------------------------------------------------
City | SALIDA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81201-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-539-9493
-----------------------------------------------------
Fax | 719-539-9496
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 OAK ST UNIT 2
-----------------------------------------------------
City | SALIDA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81201-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-539-9493
-----------------------------------------------------
Fax | 719-539-9496
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 5493
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------