=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336557750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAKE FAMILY CHIROPRACTIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2014
-----------------------------------------------------
Last Update Date | 07/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12335 WAKE UNION CHURCH RD 204
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27587-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-404-9171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12335 WAKE UNION CHURCH RD 204
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27587-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRANDON KAMINSKI
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 919-404-9171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 4344
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------