=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326348152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOLEN CLINIC LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2010
-----------------------------------------------------
Last Update Date | 10/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 S VAN BUREN ST
-----------------------------------------------------
City | WEST FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62896-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-937-4164
-----------------------------------------------------
Fax | 618-932-3203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8
-----------------------------------------------------
City | WEST FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62896-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-937-4164
-----------------------------------------------------
Fax | 618-932-3203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN ALAN NOLEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 618-937-4164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 038003613
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------