=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396929006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERRY M PAYNE D.C., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2007
-----------------------------------------------------
Last Update Date | 10/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1217 E 1ST ST
-----------------------------------------------------
City | PORT ANGELES
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98362-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-452-3017
-----------------------------------------------------
Fax | 360-452-4100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1217 E 1ST ST
-----------------------------------------------------
City | PORT ANGELES
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98362-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-452-3017
-----------------------------------------------------
Fax | 360-452-4100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERRY M PAYNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-452-3017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH00003603
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------