=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386676781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREE OF LIFE CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 06/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 174 HUNTSVILLE ROAD
-----------------------------------------------------
City | EUREKA SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-253-9117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 HUNTSVILLE ROAD
-----------------------------------------------------
City | EUREKA SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-253-9117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | JAN MARIE QUINT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 479-253-9117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1205
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------