=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386232486
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EBONY MARSHALL DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2021
-----------------------------------------------------
Last Update Date | 01/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1795 ALYSHEBA WAY STE 4103
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-335-0419
-----------------------------------------------------
Fax | 859-265-0588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 SPERLING DR APT 8105
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-497-9632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 268069
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------