=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396017331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY CHIROPRACTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2012
-----------------------------------------------------
Last Update Date | 02/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5035 SAINTS LN
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32570-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-748-0740
-----------------------------------------------------
Fax | 850-675-6886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3927 HIGHWAY 4
-----------------------------------------------------
City | JAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32565-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-675-6886
-----------------------------------------------------
Fax | 850-675-6886
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | DR. BERNARD JOSEPH KEENUM
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 850-675-6886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | CH0009285
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------