=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376823278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKPOINT CHIROPRACTIC SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2011
-----------------------------------------------------
Last Update Date | 11/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2419 MULLAN RD SUITE A
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808-1856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-541-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4411 BORDEAUX BLVD A
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808-5341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-396-5461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JARROD FANCHER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 406-396-5461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1194
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------