=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265629356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWETLIC CHIROPRACTIC & REHABILITATION CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2007
-----------------------------------------------------
Last Update Date | 06/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 WOODLAKE TRL
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43050-8113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-392-1407
-----------------------------------------------------
Fax | 740-392-0334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 WOODLAKE TRL
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43050-8113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-392-1407
-----------------------------------------------------
Fax | 740-392-0334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | MRS. BECKIE SWETLIC
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 740-392-1407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1259
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------