=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316340441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTED CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2014
-----------------------------------------------------
Last Update Date | 01/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 NC HIGHWAY 42 E
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27527-5281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-550-1099
-----------------------------------------------------
Fax | 919-550-1902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 NC HIGHWAY 42 E
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27527-5281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-550-1099
-----------------------------------------------------
Fax | 919-550-1902
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/OWNER
-----------------------------------------------------
Name | DR. BRIAN LEARY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 919-550-1099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4500
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------