=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285754085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAYLORSVILLE CHIROPRACTIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 11/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 SETTLERS CENTER RD
-----------------------------------------------------
City | TAYLORSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40071-7732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-477-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3933 MASSIE AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40207-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-896-4266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. KEVIN J. WADLE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 502-477-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | KY4328
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------