=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356746945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NODINE CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2014
-----------------------------------------------------
Last Update Date | 10/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 945 NEW BRITAIN AVE 1ST FLOOR
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06110-2230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-236-1752
-----------------------------------------------------
Fax | 860-236-0703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 945 NEW BRITAIN AVE 1ST FLOOR
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06110-2230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-236-1752
-----------------------------------------------------
Fax | 860-236-0703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. DONALD LEE NODINE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 860-236-1752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 1031
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------