=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356356018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CO-LU INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 04/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11523 KANIS RD SUITE D
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-221-4357
-----------------------------------------------------
Fax | 501-221-4379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 242161
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72223-0021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-221-4357
-----------------------------------------------------
Fax | 501-221-4379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. VANCE LEE CORNELISON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 501-221-4357
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------