=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255634838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLET FAMILY CHIROPRACTIC CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2010
-----------------------------------------------------
Last Update Date | 05/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 CHENOWETH CREEK RD
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-9795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-940-0307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 CHENOWETH CREEK RD
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-9795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-940-0307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SHERRI RENE COLLETT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 304-940-0307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 790
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------