=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386991198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CADILLAC CHIROPRACTIC,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2012
-----------------------------------------------------
Last Update Date | 08/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1736 W BELL RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85023-3414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-863-2277
-----------------------------------------------------
Fax | 602-866-7475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1736 W BELL RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85023-3414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-863-2277
-----------------------------------------------------
Fax | 602-866-7475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. EDWARD WADE RANDALL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 602-863-2277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4147
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------