=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265489074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TURNER LIFE CHIROPRACTIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 11/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4712 COUNTRY CLUB RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27104-3749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-659-0503
-----------------------------------------------------
Fax | 336-659-2660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4712 COUNTRY CLUB RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27104-3749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-659-0503
-----------------------------------------------------
Fax | 336-659-2660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROWLAND GOODRICH TURNER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 336-659-0503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1366
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------