=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285859298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTT CHIROPRACTIC CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 04/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5625 N WALL ST
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99205-6435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-482-1982
-----------------------------------------------------
Fax | 509-482-1983
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5625 N WALL ST
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99205-6435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-482-1982
-----------------------------------------------------
Fax | 509-482-1983
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SCOTT MAYSTROVICH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 509-482-1982
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | L0643329
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------